Healthcare Provider Details

I. General information

NPI: 1104246867
Provider Name (Legal Business Name): EDNA LEA CAMPBELL LPC-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EDNA LEA THOMPSON LPC

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2224 APACHE ST
CHOCTAW OK
73020-3005
US

IV. Provider business mailing address

2224 APACHE ST
CHOCTAW OK
73020-3005
US

V. Phone/Fax

Practice location:
  • Phone: 708-882-7484
  • Fax:
Mailing address:
  • Phone: 708-882-7484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10228
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP1609141
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: