Provider Demographics
NPI:1225647126
Name:CAMPOS, STEPHANIE MELISSA
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MELISSA
Last Name:CAMPOS
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 1:17862 17TH ST STE 107
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-2170
Mailing Address - Country:US
Mailing Address - Phone:714-661-5390
Mailing Address - Fax:
Practice Address - Street 1:17862 17TH ST STE 107
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2170
Practice Address - Country:US
Practice Address - Phone:714-661-5390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111341104100000X, 104100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program