Basic Information
| Provider Information | |||||||||
| NPI: | 1215260872 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPOS | ||||||||
| FirstName: | IRENE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6305 WOODMAN AVE | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914012346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189014836 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6305 WOODMAN AVE | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914012346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189014836 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2009 | ||||||||
| LastUpdateDate: | 09/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 1041C0700X | 34344 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 397 | CT | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.