Healthcare Provider Details

I. General information

NPI: 1912816489
Provider Name (Legal Business Name): THERESA CAMPBELL PMHNP- BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 COMMACK RD
ISLIP NY
11751-2604
US

IV. Provider business mailing address

25 JEFFERSON ST
EAST ISLIP NY
11730-1809
US

V. Phone/Fax

Practice location:
  • Phone: 631-954-8679
  • Fax:
Mailing address:
  • Phone: 631-954-8679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF408802-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: