Provider Demographics
NPI:1003034711
Name:WEISENBURGER, SAM (MA)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:WEISENBURGER
Suffix:
Gender:M
Credentials:MA
Other - Prefix:MR
Other - First Name:SAM
Other - Middle Name:
Other - Last Name:WEISENBURGER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:IMF
Mailing Address - Street 1:4448 UNIVERSITY AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-1759
Mailing Address - Country:US
Mailing Address - Phone:619-229-2999
Mailing Address - Fax:
Practice Address - Street 1:5348 UNIVERSITY AVE STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-8025
Practice Address - Country:US
Practice Address - Phone:619-229-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA85486106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist