=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780112334
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARRIE CAMPBELL MARRIAGE AND FAMILY THERAPY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2017
-----------------------------------------------------
Last Update Date | 05/26/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1801 OAK ST SUITE 123
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-889-8646
-----------------------------------------------------
Fax | 888-495-1490
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13061 ROSEDALE HWY G345
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-889-8646
-----------------------------------------------------
Fax | 888-495-1490
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MS. CARRIE LEIGH CAMPBELL
-----------------------------------------------------
Credential | MS, LMFT
-----------------------------------------------------
Telephone | 661-889-8646
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 82962
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------