MEDICARE: CORY CAMPBELL LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	C4610	OR
2	101YP2500X	Professional Counselor	LPC-19959	AZ

General Provider Information

NPI Number	:	1053959239
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORY CAMPBELL LPC

Provider Business Mailing Address
First Line	:	PO BOX 12932
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85732-2932
Country	:	US
Telephone Number	:	541-476-2373
Fax Number	:

Provider Business Practice Location Address
First Line	:	5113 N SOLDIER TRL
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85749-8910
Country	:	US
Telephone Number	:	541-241-2048
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2019
Last Update Date	:	09/28/2021

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