MEDICARE: LIZA NOEMI CAMPOS LMFT113256

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	IMF 96465	CA
2	225400000X	Rehabilitation Practitioner
3	390200000X	Student in an Organized Health Care Education/Training Program
4	106H00000X	Marriage & Family Therapist	113256	CA

General Provider Information

NPI Number	:	1023490539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIZA NOEMI CAMPOS LMFT113256

Provider Business Mailing Address
First Line	:	2500 E FOOTHILL BLVD STE 300
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91107-7102
Country	:	US
Telephone Number	:	626-993-3000
Fax Number	:

Provider Business Practice Location Address
First Line	:	12598 CENTRAL AVE STE 202
Second Line	:
City	:	CHINO
State	:	CA
Zip	:	91710-3530
Country	:	US
Telephone Number	:	909-576-3889
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2015
Last Update Date	:	03/30/2021

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