Healthcare Provider Details

I. General information

NPI: 1982958781
Provider Name (Legal Business Name): NICHOLAS BRIAN CAMPBELL CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2012
Last Update Date: 10/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6746 CLAYTON AVE
SAINT LOUIS MO
63139-3756
US

IV. Provider business mailing address

6746 CLAYTON AVE
SAINT LOUIS MO
63139-3756
US

V. Phone/Fax

Practice location:
  • Phone: 314-645-4845
  • Fax:
Mailing address:
  • Phone: 314-645-4845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2012017953
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: