Healthcare Provider Details

I. General information

NPI: 1538839402
Provider Name (Legal Business Name): ASHLEY FAWN CAMPBELL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY FAWN HOFFMAN

II. Dates (important events)

Enumeration Date: 09/14/2021
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 E 10TH ST
ROLLA MO
65401-3648
US

IV. Provider business mailing address

1800 COMMUNITY
CLINTON MO
64735-8804
US

V. Phone/Fax

Practice location:
  • Phone: 888-403-1071
  • Fax:
Mailing address:
  • Phone: 660-885-8131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2021035608
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number2016027667
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: