Provider Demographics
NPI:1407509987
Name:MAGANA, FIDDE SAMANTHA
Entity Type:Individual
Prefix:
First Name:FIDDE
Middle Name:SAMANTHA
Last Name:MAGANA
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 1:2155 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2204
Mailing Address - Country:US
Mailing Address - Phone:951-357-6926
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:2155 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2204
Practice Address - Country:US
Practice Address - Phone:951-357-6926
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2022-02-03
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician