Provider Demographics
NPI:1205216843
Name:NUSBAUM, SAMANTHA E
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:E
Last Name:NUSBAUM
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 1:1281 9TH AVE UNIT 1312
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-4656
Mailing Address - Country:US
Mailing Address - Phone:516-316-1110
Mailing Address - Fax:
Practice Address - Street 1:1281 9TH AVE UNIT 1312
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-4656
Practice Address - Country:US
Practice Address - Phone:516-316-1110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14913225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA14913OtherCALIFORNIA OT LICENSE