Healthcare Provider Details

I. General information

NPI: 1750020954
Provider Name (Legal Business Name): CAMPBELL INTEGRATIVE PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2022
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 GREENSBORO DR STE 900
MC LEAN VA
22102-4931
US

IV. Provider business mailing address

8200 GREENSBORO DR STE 900
MC LEAN VA
22102-4931
US

V. Phone/Fax

Practice location:
  • Phone: 571-255-9859
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. SHUSHAN CAMPBELL
Title or Position: PSYCHOLOGIST/CLINUCAL DIRECTOR
Credential:
Phone: 571-255-9859