Provider Demographics
NPI:1821204272
Name:CAMPO, COLLEEN KEENAN (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:KEENAN
Last Name:CAMPO
Suffix:
Gender:F
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 E 82ND ST APT 4L
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-4912
Mailing Address - Country:US
Mailing Address - Phone:312-771-0790
Mailing Address - Fax:
Practice Address - Street 1:180 E 79TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-0437
Practice Address - Country:US
Practice Address - Phone:212-744-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000485-1101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000485-1OtherSTATE LICENSE NUMBER