Healthcare Provider Details

I. General information

NPI: 1871721555
Provider Name (Legal Business Name): ANDRE GREGROLLE JOHN CAMPBELL M.A.,LMFT.LADC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 07/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 EAST 15TH STREET SUITE 205
TULSA OK
74104
US

IV. Provider business mailing address

2510 E. 15TH ST.
TULSA OK
74104
US

V. Phone/Fax

Practice location:
  • Phone: 918-508-2750
  • Fax: 918-744-4432
Mailing address:
  • Phone: 918-508-2750
  • Fax: 918-744-4432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number968
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number997
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: