Provider Demographics
NPI:1114573987
Name:VALLE, SAMANTHA SELENE
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:SELENE
Last Name:VALLE
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 1:120 W MAIN ST STE 220
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-4224
Mailing Address - Country:US
Mailing Address - Phone:469-615-8184
Mailing Address - Fax:
Practice Address - Street 1:120 W MAIN ST STE 220
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-4224
Practice Address - Country:US
Practice Address - Phone:469-615-8184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty