Healthcare Provider Details

I. General information

NPI: 1952210924
Provider Name (Legal Business Name): LISA CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 8TH AVE
FT WORTH TX
76110-1352
US

IV. Provider business mailing address

18 WORTHINGTON DR
UNION MO
63084-4443
US

V. Phone/Fax

Practice location:
  • Phone: 806-220-5955
  • Fax:
Mailing address:
  • Phone: 806-220-5955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number103622
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: