Provider Demographics
NPI:1821975863
Name:CAMPBELL, LIDA (MFA, DSP, CESP)
Entity type:Individual
Prefix:
First Name:LIDA
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MFA, DSP, CESP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1064 BOURGOGNE AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-1504
Mailing Address - Country:US
Mailing Address - Phone:419-378-1976
Mailing Address - Fax:
Practice Address - Street 1:1064 BOURGOGNE AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-1504
Practice Address - Country:US
Practice Address - Phone:419-378-1976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-20
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care