MEDICARE: DR. MARC ANTHONY CAMPOS-PANTOJA LCSW, PSYD

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	1041C0700X	Clinical Social Worker
2	1041C0700X	Clinical Social Worker	ASW 14648	CA
3	1041C0700X	Clinical Social Worker		CA
4	1041C0700X	Clinical Social Worker	25797	CA
5	103TC0700X	Clinical Psychologist	94028409	CA

General Provider Information

NPI Number	:	1487715785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARC ANTHONY CAMPOS-PANTOJA LCSW, PSYD

Provider Business Mailing Address
First Line	:	22539 2ND ST
Second Line	:
City	:	HAYWARD
State	:	CA
Zip	:	94541-4111
Country	:	US
Telephone Number	:	510-886-2485
Fax Number	:

Provider Business Practice Location Address
First Line	:	9412 BIG HORN BLVD STE 6
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95758-1101
Country	:	US
Telephone Number	:	916-226-2812
Fax Number	:

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

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	08/26/2024

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