Provider Demographics
NPI:1811546989
Name:CAMPUZANO, JOSE LUIS
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:CAMPUZANO
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 1:21600 OXNARD ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-4976
Mailing Address - Country:US
Mailing Address - Phone:818-345-2345
Mailing Address - Fax:
Practice Address - Street 1:3400 STATE ST STE G750
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-7012
Practice Address - Country:US
Practice Address - Phone:971-273-7502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA104659106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician