Provider Demographics
NPI:1649086513
Name:CAMPOS, MARISA LYNN
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:LYNN
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 1:15230 LA VALLE ST
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-3755
Mailing Address - Country:US
Mailing Address - Phone:818-270-5844
Mailing Address - Fax:
Practice Address - Street 1:762 GRISWOLD AVE
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-2105
Practice Address - Country:US
Practice Address - Phone:747-500-9405
Practice Address - Fax:747-500-9415
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1587221124101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)