Provider Demographics
NPI:1871721555
Name:CAMPBELL, ANDRE GREGROLLE JOHN (MA,LMFTLADC)
Entity type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:GREGROLLE JOHN
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:MA,LMFTLADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 E. 15TH ST.
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104
Mailing Address - Country:US
Mailing Address - Phone:918-508-2750
Mailing Address - Fax:918-744-4432
Practice Address - Street 1:2510 EAST 15TH STREET
Practice Address - Street 2:SUITE 205
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104
Practice Address - Country:US
Practice Address - Phone:918-508-2750
Practice Address - Fax:918-744-4432
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-01
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK968101YA0400X
OK997106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)