=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740778869
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANNE CAMPBELL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2018
-----------------------------------------------------
Last Update Date | 04/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4301 W MARKHAM ST # 728
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72205-7101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-686-7864
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13212 WILLOW BEACH RD
-----------------------------------------------------
City | NORTH LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72117-9307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-517-8389
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 871-C
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------