Provider Demographics
NPI:1225567548
Name:SEPULVADO, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:SEPULVADO
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 1:671 HIGHWAY 171 STE C
Mailing Address - Street 2:
Mailing Address - City:STONEWALL
Mailing Address - State:LA
Mailing Address - Zip Code:71078-6100
Mailing Address - Country:US
Mailing Address - Phone:318-775-4124
Mailing Address - Fax:318-775-4384
Practice Address - Street 1:671 HIGHWAY 171 STE C
Practice Address - Street 2:
Practice Address - City:STONEWALL
Practice Address - State:LA
Practice Address - Zip Code:71078-6100
Practice Address - Country:US
Practice Address - Phone:318-775-4124
Practice Address - Fax:318-775-4384
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA462556190Medicaid