Healthcare Provider Details

I. General information

NPI: 1174427918
Provider Name (Legal Business Name): WARREN BRUCE CAMPBELL LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5725 LOFTUS LN
SAVAGE MN
55378-2717
US

IV. Provider business mailing address

1273 HILLSIDE CIR
CHASKA MN
55318-1715
US

V. Phone/Fax

Practice location:
  • Phone: 952-952-6120
  • Fax:
Mailing address:
  • Phone: 828-776-9240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number307692
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: