Provider Demographics
NPI:1538481486
Name:CAMPOS, MICHAEL DAVID (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:CAMPOS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1334 WESTWOOD BLVD STE 2B
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4951
Mailing Address - Country:US
Mailing Address - Phone:310-663-8936
Mailing Address - Fax:
Practice Address - Street 1:1334 WESTWOOD BLVD STE 2B
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024
Practice Address - Country:US
Practice Address - Phone:310-663-8936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-19
Last Update Date:2018-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23145103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical