Provider Demographics
NPI:1003586124
Name:POLING, SAMANTHA SOKUNTHEA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:SOKUNTHEA
Last Name:POLING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1913 CORTE MARAVILLA
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-4627
Mailing Address - Country:US
Mailing Address - Phone:619-241-9040
Mailing Address - Fax:
Practice Address - Street 1:13920 CITY CENTER DR STE 290
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-5444
Practice Address - Country:US
Practice Address - Phone:866-351-8887
Practice Address - Fax:626-737-1095
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician