Provider Demographics
NPI:1548735707
Name:PALACIOS CAMPOS, VICTOR
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:PALACIOS CAMPOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 S GRADY WAY STE 500
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-3217
Mailing Address - Country:US
Mailing Address - Phone:910-289-5411
Mailing Address - Fax:
Practice Address - Street 1:15 S GRADY WAY STE 500
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-3217
Practice Address - Country:US
Practice Address - Phone:425-444-5902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60894074101YM0800X
WALH61071652101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health