Provider Demographics
NPI:1104364215
Name:CHUANG, SAMUEL I
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:CHUANG
Suffix:I
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 1:642 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-3232
Mailing Address - Country:US
Mailing Address - Phone:626-384-7734
Mailing Address - Fax:
Practice Address - Street 1:424 PENINSULA AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-1653
Practice Address - Country:US
Practice Address - Phone:650-286-4396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA91690066D53091Medicaid