Provider Demographics
NPI:1144413881
Name:CAMPILLO-PETERS, MICHELLE DENISE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:DENISE
Last Name:CAMPILLO-PETERS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12171 WORLD TRADE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-3709
Mailing Address - Country:US
Mailing Address - Phone:858-674-4480
Mailing Address - Fax:858-674-0769
Practice Address - Street 1:12171 WORLD TRADE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3709
Practice Address - Country:US
Practice Address - Phone:858-674-4480
Practice Address - Fax:858-674-0769
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 8475225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant