Provider Demographics
NPI:1821794579
Name:CAMPO, TODD RUSSELL JR (AMFT)
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:RUSSELL
Last Name:CAMPO
Suffix:JR
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9835
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92728-9835
Mailing Address - Country:US
Mailing Address - Phone:714-883-4483
Mailing Address - Fax:
Practice Address - Street 1:401 W CIVIC CENTER DR
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4515
Practice Address - Country:US
Practice Address - Phone:714-883-4483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-03
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT137580106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist