Provider Demographics
NPI:1255688032
Name:PANAMENO CAMPOS, JAVIER MARTIN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JAVIER
Middle Name:MARTIN
Last Name:PANAMENO CAMPOS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:JAVIER
Other - Middle Name:MARTIN
Other - Last Name:PANAMENO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCS
Mailing Address - Street 1:16025 PEACH TREE LN
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92337-1010
Mailing Address - Country:US
Mailing Address - Phone:909-904-0667
Mailing Address - Fax:
Practice Address - Street 1:255 TERRACINA BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4870
Practice Address - Country:US
Practice Address - Phone:909-798-1763
Practice Address - Fax:909-307-6405
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 261271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical