Healthcare Provider Details

I. General information

NPI: 1053483693
Provider Name (Legal Business Name): GABRIEL DYLAN CAMPBELL MS LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 LAKE BOONE TRL
RALEIGH NC
27607-2934
US

IV. Provider business mailing address

109 BROOK HOLLOW CT
CARY NC
27513-4932
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-9182
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4558
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: