Provider Demographics
NPI:1154535086
Name:CAMPO, ANGENE (MCD, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ANGENE
Middle Name:
Last Name:CAMPO
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2451 N MCMULLEN BOOTH RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-1356
Mailing Address - Country:US
Mailing Address - Phone:727-797-4811
Mailing Address - Fax:
Practice Address - Street 1:2451 N MCMULLEN BOOTH RD
Practice Address - Street 2:SUITE 200
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-1356
Practice Address - Country:US
Practice Address - Phone:727-797-4811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 4978235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist