Basic Information
| Provider Information | |||||||||
| NPI: | 1992217079 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAMPOS | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | ABIGAIL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20355 SORRENTO LN APT 307 | ||||||||
| Address2: | |||||||||
| City: | PORTER RANCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913264581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8184916297 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11301 WILSHIRE BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900731003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104783711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.