Provider Demographics
NPI:1710622964
Name:CAMPOS, NICOLE MICHELE (BA)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:MICHELE
Last Name:CAMPOS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1647 DEWITT ESTATES RD
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-3060
Mailing Address - Country:US
Mailing Address - Phone:619-647-6781
Mailing Address - Fax:
Practice Address - Street 1:1647 DEWITT ESTATES RD
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-3060
Practice Address - Country:US
Practice Address - Phone:619-647-6781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician