Provider Demographics
NPI:1437285756
Name:CAMPO, ANNETTE IRENE (MFT)
Entity Type:Individual
Prefix:MS
First Name:ANNETTE
Middle Name:IRENE
Last Name:CAMPO
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 FORD AVE
Mailing Address - Street 2:STE.1
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4631
Mailing Address - Country:US
Mailing Address - Phone:209-572-0984
Mailing Address - Fax:
Practice Address - Street 1:1604 FORD AVE
Practice Address - Street 2:STE.1
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4631
Practice Address - Country:US
Practice Address - Phone:209-572-0984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC44151106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist