Provider Demographics
NPI:1770059503
Name:CAMPBELL, TIMOTHY (BA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20525 DETROIT RD STE 8
Mailing Address - Street 2:
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116-2444
Mailing Address - Country:US
Mailing Address - Phone:216-777-8834
Mailing Address - Fax:216-502-2291
Practice Address - Street 1:20525 DETROIT RD STE 8
Practice Address - Street 2:
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116-2444
Practice Address - Country:US
Practice Address - Phone:216-777-8834
Practice Address - Fax:216-502-2291
Is Sole Proprietor?:No
Enumeration Date:2018-10-19
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1801174-TRNE101YP2500X
OHE.2102535101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional