Healthcare Provider Details

I. General information

NPI: 1700715273
Provider Name (Legal Business Name): MADISON GRACE CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 WOLF CREEK TRL
ABINGDON VA
24210-2536
US

IV. Provider business mailing address

1605 NEWTON ST
BRISTOL VA
24201-3747
US

V. Phone/Fax

Practice location:
  • Phone: 276-388-9483
  • Fax:
Mailing address:
  • Phone: 276-791-4101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119011413
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: