Provider Demographics
NPI:1487715785
Name:CAMPOS-PANTOJA, MARC ANTHONY (LCSW, PSYD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:ANTHONY
Last Name:CAMPOS-PANTOJA
Suffix:
Gender:M
Credentials:LCSW, PSYD
Other - Prefix:MR
Other - First Name:MARC
Other - Middle Name:ANTHONY
Other - Last Name:CAMPOS-RAMOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22539 2ND ST
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-4111
Mailing Address - Country:US
Mailing Address - Phone:510-886-2485
Mailing Address - Fax:
Practice Address - Street 1:9412 BIG HORN BLVD STE 6
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-1101
Practice Address - Country:US
Practice Address - Phone:916-226-2812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
CAASW 146481041C0700X
CA1041C0700X
CA257971041C0700X
CA94028409103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical