Provider Demographics
NPI:1568982635
Name:CAMPBELL HENDERSON, TRACEY LYNETTE (RN)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNETTE
Last Name:CAMPBELL HENDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 630164
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75963-0164
Mailing Address - Country:US
Mailing Address - Phone:936-205-1875
Mailing Address - Fax:
Practice Address - Street 1:10000 N 31ST AVE STE C262
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-9630
Practice Address - Country:US
Practice Address - Phone:602-754-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2025-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TX1214661163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA473292439Medicaid