Provider Demographics
NPI:1043786502
Name:CAMPUZANO, IVONNE THELMA
Entity Type:Individual
Prefix:
First Name:IVONNE
Middle Name:THELMA
Last Name:CAMPUZANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 WILSHIRE BLVD 9TH FL
Mailing Address - Street 2:UNIT #574
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-4025
Mailing Address - Country:US
Mailing Address - Phone:213-955-7250
Mailing Address - Fax:
Practice Address - Street 1:611 WILSHIRE BLVD
Practice Address - Street 2:9TH FLOOR, UNIT #574
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017
Practice Address - Country:US
Practice Address - Phone:213-955-7250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT109225101YM0800X, 106H00000X
225400000X
CALMFT123631106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner