Provider Demographics
NPI:1750178547
Name:CAMPOS, ROGER G
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:G
Last Name:CAMPOS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-3504
Mailing Address - Country:US
Mailing Address - Phone:415-225-6294
Mailing Address - Fax:
Practice Address - Street 1:234 FILLMORE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-3504
Practice Address - Country:US
Practice Address - Phone:415-225-6294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT152590101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health