Provider Demographics
NPI:1144353806
Name:CAMPBELL, VICKIE A (CCC-CLP)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:A
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:CCC-CLP
Other - Prefix:
Other - First Name:VICI
Other - Middle Name:
Other - Last Name:POTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6360 TECHSTER BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-4805
Mailing Address - Country:US
Mailing Address - Phone:239-223-2751
Mailing Address - Fax:239-561-2933
Practice Address - Street 1:6360 TECHSTER BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-4805
Practice Address - Country:US
Practice Address - Phone:239-223-2751
Practice Address - Fax:239-561-2933
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5965235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL886303200Medicaid