Provider Demographics
NPI:1578309209
Name:CAMPBELL, KADIJAH (LAC)
Entity type:Individual
Prefix:
First Name:KADIJAH
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622-624 VALLEY RD STE 5G-5H
Mailing Address - Street 2:
Mailing Address - City:UPPER MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-1462
Mailing Address - Country:US
Mailing Address - Phone:908-922-6404
Mailing Address - Fax:
Practice Address - Street 1:622-624 VALLEY RD STE 5G-5H
Practice Address - Street 2:
Practice Address - City:UPPER MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07043-1462
Practice Address - Country:US
Practice Address - Phone:732-674-9857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00803600101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor