Basic Information
Provider Information | |||||||||
NPI: | 1457642720 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CAMPOS | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: | ANNETTE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMHC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4425 MILITARY TRL | ||||||||
Address2: | #203 | ||||||||
City: | JUPITER | ||||||||
State: | FL | ||||||||
PostalCode: | 334584819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5617472775 | ||||||||
FaxNumber: | 5617471881 | ||||||||
Practice Location | |||||||||
Address1: | 4425 MILITARY TRL | ||||||||
Address2: | #203 | ||||||||
City: | JUPITER | ||||||||
State: | FL | ||||||||
PostalCode: | 334584819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5617472775 | ||||||||
FaxNumber: | 5617471881 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/21/2011 | ||||||||
LastUpdateDate: | 11/06/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   | 101YM0800X | MH9360 | FL | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 002147800 | 05 | FL |   | MEDICAID |