Provider Demographics
NPI:1124658091
Name:CAMPOS, FERNANDO
Entity type:Individual
Prefix:MR
First Name:FERNANDO
Middle Name:
Last Name:CAMPOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2419 E COMMERCIAL BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4042
Mailing Address - Country:US
Mailing Address - Phone:954-391-5305
Mailing Address - Fax:
Practice Address - Street 1:2419 E COMMERCIAL BLVD STE 203
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4042
Practice Address - Country:US
Practice Address - Phone:954-391-5305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT3632101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health