Provider Demographics
NPI:1003671942
Name:CAMPOS, CARLA MARIA (252Y00000X)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:MARIA
Last Name:CAMPOS
Suffix:
Gender:F
Credentials:252Y00000X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-2133
Mailing Address - Country:US
Mailing Address - Phone:845-360-6641
Mailing Address - Fax:845-360-9076
Practice Address - Street 1:124 MAIN ST
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-2133
Practice Address - Country:US
Practice Address - Phone:845-360-6641
Practice Address - Fax:845-360-9076
Is Sole Proprietor?:No
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY660027907171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator