=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164526190
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUCINDRA CAMPBELL PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4715 VIEWRIDGE AVE STE 230
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92123-1680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-257-8715
-----------------------------------------------------
Fax | 800-819-1655
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4115 WOODLAKE LN
-----------------------------------------------------
City | MISSOURI CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77459-4331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-704-2601
-----------------------------------------------------
Fax | 281-649-3000
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 606088
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------