Provider Demographics
NPI:1033649942
Name:SAMUEL, BYRON D JR
Entity Type:Individual
Prefix:
First Name:BYRON
Middle Name:D
Last Name:SAMUEL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15141 WAVECREST DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-5391
Mailing Address - Country:US
Mailing Address - Phone:951-564-7287
Mailing Address - Fax:
Practice Address - Street 1:41769 ENTERPRISE CIR N
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5626
Practice Address - Country:US
Practice Address - Phone:951-303-8255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral