Healthcare Provider Details

I. General information

NPI: 1508983594
Provider Name (Legal Business Name): JUAN MANUEL CAMPOS MFTINT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 CLAUS RD
MODESTO CA
95355-9711
US

IV. Provider business mailing address

2144 COBBLESTONE MNR
MODESTO CA
95355-9185
US

V. Phone/Fax

Practice location:
  • Phone: 209-558-4600
  • Fax: 209-558-4729
Mailing address:
  • Phone: 209-551-4223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMF43209
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: