Provider Demographics
NPI:1962810705
Name:CAMPOS GONZALES, ANGELICA
Entity type:Individual
Prefix:MS
First Name:ANGELICA
Middle Name:
Last Name:CAMPOS GONZALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGELICA
Other - Middle Name:
Other - Last Name:CAMPOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1605 EASTLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1009
Mailing Address - Country:US
Mailing Address - Phone:688-323-8826
Mailing Address - Fax:
Practice Address - Street 1:1605 EASTLAKE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1009
Practice Address - Country:US
Practice Address - Phone:688-323-8826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-24
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X, 101YM0800X
CALCSW1118211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health