Provider Demographics
NPI:1487415642
Name:FORREST CAMPOS, CARLA PATRICIA (LAC, MSOM)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:PATRICIA
Last Name:FORREST CAMPOS
Suffix:
Gender:F
Credentials:LAC, MSOM
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:PATRICIA
Other - Last Name:DEL POZO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2417 W APPLE TREE RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-3313
Mailing Address - Country:US
Mailing Address - Phone:414-573-3969
Mailing Address - Fax:
Practice Address - Street 1:130 W BRUCE ST STE 300
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-1667
Practice Address - Country:US
Practice Address - Phone:414-384-2673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X
WI55-828171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral