Provider Demographics
NPI:1538630173
Name:CAMPBELL, CODY PATRICK
Entity type:Individual
Prefix:MR
First Name:CODY
Middle Name:PATRICK
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 ERIE BLVD W STE 208
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2457
Mailing Address - Country:US
Mailing Address - Phone:315-472-7363
Mailing Address - Fax:315-701-2368
Practice Address - Street 1:620 ERIE BLVD W STE 208
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-2457
Practice Address - Country:US
Practice Address - Phone:315-472-7363
Practice Address - Fax:315-701-2368
Is Sole Proprietor?:No
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY105603104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker