Healthcare Provider Details

I. General information

NPI: 1568185569
Provider Name (Legal Business Name): KATHRYN LILLY CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 ROUTE 22
BRIDGEWATER NJ
08807-2405
US

IV. Provider business mailing address

61 WENONAH AVE
LAKE HIAWATHA NJ
07034-2719
US

V. Phone/Fax

Practice location:
  • Phone: 908-722-1881
  • Fax:
Mailing address:
  • Phone: 973-879-8815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SL06852000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL06852000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: