Provider Demographics
NPI:1194035253
Name:SAMPSON, LATISHA (MSW)
Entity Type:Individual
Prefix:MS
First Name:LATISHA
Middle Name:
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1529 EAST PALMDALE BLVD.
Mailing Address - Street 2:STE. 210
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-2029
Mailing Address - Country:US
Mailing Address - Phone:661-272-9996
Mailing Address - Fax:
Practice Address - Street 1:1529 E PALMDALE BLVD STE 210
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-2029
Practice Address - Country:US
Practice Address - Phone:661-272-9996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA257341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00007301Medicaid