Provider Demographics
NPI:1437625761
Name:WORRALL, SAM DUANE
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:DUANE
Last Name:WORRALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6235 RIVER CREST DR STE O
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-0758
Mailing Address - Country:US
Mailing Address - Phone:951-742-7561
Mailing Address - Fax:
Practice Address - Street 1:755 W HOFFER ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-2348
Practice Address - Country:US
Practice Address - Phone:951-992-2563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-14
Last Update Date:2018-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist