Provider Demographics
NPI:1245732114
Name:CAMPOS, LETICIA ALEJANDRA
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:ALEJANDRA
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 1:9416 TIMBERLEAF DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-6124
Mailing Address - Country:US
Mailing Address - Phone:214-641-4835
Mailing Address - Fax:
Practice Address - Street 1:5242 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-5001
Practice Address - Country:US
Practice Address - Phone:214-641-4835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106270235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX106270OtherTEXAS SLP LICENSE
TX106270OtherSTATE LICENSE