Provider Demographics
NPI:1508983594
Name:CAMPOS, JUAN MANUEL (MFTINT)
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:MANUEL
Last Name:CAMPOS
Suffix:
Gender:M
Credentials:MFTINT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2144 COBBLESTONE MNR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-9185
Mailing Address - Country:US
Mailing Address - Phone:209-551-4223
Mailing Address - Fax:
Practice Address - Street 1:1501 CLAUS RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-9711
Practice Address - Country:US
Practice Address - Phone:209-558-4600
Practice Address - Fax:209-558-4729
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF43209101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health