Provider Demographics
NPI:1144504382
Name:CAMPBELL, LAURIE J
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:J
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9850 163RD ST W
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-4755
Mailing Address - Country:US
Mailing Address - Phone:612-708-2027
Mailing Address - Fax:952-236-4687
Practice Address - Street 1:9850 163RD ST W
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-9471
Practice Address - Country:US
Practice Address - Phone:612-708-2027
Practice Address - Fax:952-236-4687
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225700000X
172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist