Provider Demographics
NPI:1023490539
Name:CAMPOS, LIZA NOEMI (LMFT113256)
Entity type:Individual
Prefix:
First Name:LIZA
Middle Name:NOEMI
Last Name:CAMPOS
Suffix:
Gender:F
Credentials:LMFT113256
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 E FOOTHILL BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-7102
Mailing Address - Country:US
Mailing Address - Phone:626-993-3000
Mailing Address - Fax:
Practice Address - Street 1:12598 CENTRAL AVE STE 202
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-3530
Practice Address - Country:US
Practice Address - Phone:909-576-3889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 96465106H00000X
225400000X, 390200000X
CA113256106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program