Healthcare Provider Details

I. General information

NPI: 1114042173
Provider Name (Legal Business Name): SANDRA LOVE-CAMPBELL SWT, CAC1
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 12 MILE RD
BERKLEY MI
48072-1630
US

IV. Provider business mailing address

29275 TESSMER CT
MADISON HEIGHTS MI
48071-2619
US

V. Phone/Fax

Practice location:
  • Phone: 248-543-1090
  • Fax: 248-543-0017
Mailing address:
  • Phone: 248-543-1090
  • Fax: 248-543-0017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6803073683
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: