Provider Demographics
NPI:1013622729
Name:CAMPONOVO, VANTRANIQUE ( VANNA) T (MA,LCDC,CSAT-C)
Entity Type:Individual
Prefix:MRS
First Name:VANTRANIQUE ( VANNA)
Middle Name:T
Last Name:CAMPONOVO
Suffix:
Gender:F
Credentials:MA,LCDC,CSAT-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 LIPSCOMB ST # D
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3125
Mailing Address - Country:US
Mailing Address - Phone:817-829-1214
Mailing Address - Fax:
Practice Address - Street 1:917 LIPSCOMB ST # D
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3125
Practice Address - Country:US
Practice Address - Phone:817-829-1214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16075101YA0400X
CSAT-2021-3573101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor