Healthcare Provider Details

I. General information

NPI: 1316341365
Provider Name (Legal Business Name): NICHOLE MONIC CAMPOS LPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2014
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 S ARROYO PKWY
PASADENA CA
91105-3911
US

IV. Provider business mailing address

300 N SHADYGLEN DR
COVINA CA
91724-2911
US

V. Phone/Fax

Practice location:
  • Phone: 626-254-5000
  • Fax:
Mailing address:
  • Phone: 626-498-5250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT 37808
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: