Healthcare Provider Details

I. General information

NPI: 1114484870
Provider Name (Legal Business Name): TIARA MARIE CAMPOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2019
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 DELA VINA AVE
MONTEREY CA
93940-3974
US

IV. Provider business mailing address

343 DELA VINA AVE
MONTEREY CA
93940-3974
US

V. Phone/Fax

Practice location:
  • Phone: 831-440-7030
  • Fax:
Mailing address:
  • Phone: 831-440-7030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: