Provider Demographics
NPI:1790341394
Name:CAMPOS, ELSA ROSARIO
Entity Type:Individual
Prefix:
First Name:ELSA
Middle Name:ROSARIO
Last Name:CAMPOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11590 W BERNARDO CT STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-1624
Mailing Address - Country:US
Mailing Address - Phone:858-432-4749
Mailing Address - Fax:
Practice Address - Street 1:1197 E 7TH ST
Practice Address - Street 2:
Practice Address - City:CALEXICO
Practice Address - State:CA
Practice Address - Zip Code:92231-2964
Practice Address - Country:US
Practice Address - Phone:760-960-5365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician