Basic Information
| Provider Information | |||||||||
| NPI: | 1265628200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPOS | ||||||||
| FirstName: | NATOSHA | ||||||||
| MiddleName: | LABELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC, LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 46 ALBION ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066052602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033306000 | ||||||||
| FaxNumber: | 2033306008 | ||||||||
| Practice Location | |||||||||
| Address1: | 46 ALBION ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066052602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033306000 | ||||||||
| FaxNumber: | 2033306008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2007 | ||||||||
| LastUpdateDate: | 10/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | 01171 | CT | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 001171 | 01 | CT | STATE LICENSE | OTHER | 004236148 | 05 | CT | MEDICAID |