Provider Demographics
NPI:1033494703
Name:SAMUEL, MARYANN (PSYD)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:MARYANN
Other - Middle Name:
Other - Last Name:HENEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:92 ARGONAUT STE 245
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-4129
Mailing Address - Country:US
Mailing Address - Phone:949-887-8779
Mailing Address - Fax:
Practice Address - Street 1:25255 CABOT RD
Practice Address - Street 2:SUITE #210
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-5519
Practice Address - Country:US
Practice Address - Phone:949-887-8779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-13
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 24440103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist