Healthcare Provider Details

I. General information

NPI: 1689124299
Provider Name (Legal Business Name): CASSANDRA CAMPOS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 10/10/2022
Certification Date: 10/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W 21ST ST
CLOVIS NM
88101-4151
US

IV. Provider business mailing address

657 NICKLAUS DR SE
RIO RANCHO NM
87124-3431
US

V. Phone/Fax

Practice location:
  • Phone: 575-769-2345
  • Fax:
Mailing address:
  • Phone: 505-301-3963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: