Provider Demographics
NPI:1316341365
Name:CAMPOS, NICHOLE MONIC (LPT)
Entity type:Individual
Prefix:MS
First Name:NICHOLE
Middle Name:MONIC
Last Name:CAMPOS
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N SHADYGLEN DR
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-2911
Mailing Address - Country:US
Mailing Address - Phone:626-498-5250
Mailing Address - Fax:
Practice Address - Street 1:1020 S ARROYO PKWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3911
Practice Address - Country:US
Practice Address - Phone:626-254-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 37808167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician