Basic Information
| Provider Information | |||||||||
| NPI: | 1164187068 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAMPOS | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | ULISES | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11053 RANCHITO ST | ||||||||
| Address2: | |||||||||
| City: | EL MONTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917311431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235517784 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3455 PERCY ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900231716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232682100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2021 | ||||||||
| LastUpdateDate: | 11/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 105051 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.