=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952108409
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAMPOS MENTAL HEALTH COUNSELING, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2025
-----------------------------------------------------
Last Update Date | 09/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 USHERS RD STE 210
-----------------------------------------------------
City | BALLSTON LAKE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12019-1555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-251-2834
-----------------------------------------------------
Fax | 929-322-9200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 315 USHERS RD STE 210
-----------------------------------------------------
City | BALLSTON LAKE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12019-1555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-251-2834
-----------------------------------------------------
Fax | 929-322-9200
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. JULISSA MARTINEZ
-----------------------------------------------------
Credential | LMHC-D, NCC, CASAC
-----------------------------------------------------
Telephone | 347-251-2834
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------