MEDICARE: MOSELLE CAMPBELL

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	103TC0700X	Clinical Psychologist	003967	CT
2	103TC2200X	Clinical Child & Adolescent Psychologist	3967	CT
3	103TC2200X	Clinical Child & Adolescent Psychologist	PSY50000441	MA

General Provider Information

NPI Number	:	1588278550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOSELLE CAMPBELL

Provider Business Mailing Address
First Line	:	81 HARTWELL AVE STE 310
Second Line	:
City	:	LEXINGTON
State	:	MA
Zip	:	02421-3160
Country	:	US
Telephone Number	:	781-541-4464
Fax Number	:

Provider Business Practice Location Address
First Line	:	81 HARTWELL AVE STE 310
Second Line	:
City	:	LEXINGTON
State	:	MA
Zip	:	02421-3160
Country	:	US
Telephone Number	:	781-541-4464
Fax Number	:

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

Provider Enumeration Date	:	09/07/2020
Last Update Date	:	01/02/2024

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Directions to “ MOSELLE CAMPBELL ” Practice Location

Language	Start Address	Practice Location

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