MEDICARE: ALYSSA DANIELLE 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	106S00000X	Behavior Technician		NM

General Provider Information

NPI Number	:	1710584321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALYSSA DANIELLE CAMPBELL

Provider Business Mailing Address
First Line	:	1405 SAN CARLOS RD SW APT 5
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87104-1060
Country	:	US
Telephone Number	:	505-514-1160
Fax Number	:

Provider Business Practice Location Address
First Line	:	1405 SAN CARLOS RD SW APT 5
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87104-1060
Country	:	US
Telephone Number	:	505-514-1160
Fax Number	:

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

Provider Enumeration Date	:	10/06/2020
Last Update Date	:	10/06/2020

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