Provider Demographics
NPI:1962934257
Name:CAMPO, ENRIQUE A
Entity type:Individual
Prefix:MR
First Name:ENRIQUE
Middle Name:A
Last Name:CAMPO
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:PO BOX 11253
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92711-1253
Mailing Address - Country:US
Mailing Address - Phone:949-891-2760
Mailing Address - Fax:888-280-6765
Practice Address - Street 1:5000 BIRCH STREET, WEST TOWER
Practice Address - Street 2:SUITE 306
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660
Practice Address - Country:US
Practice Address - Phone:949-891-2760
Practice Address - Fax:888-280-6765
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF98305106H00000X
CA114768106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA114768OtherBOARD OF BEHAVIORAL SCIENCES