Provider Demographics
NPI:1467050831
Name:SAMUELSON, MICHAEL JOSEPH
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:SAMUELSON
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 1:2801 BRISTOL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5996
Mailing Address - Country:US
Mailing Address - Phone:714-850-8463
Mailing Address - Fax:
Practice Address - Street 1:2801 BRISTOL ST STE 200
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5996
Practice Address - Country:US
Practice Address - Phone:714-850-8463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2022-05-05
Deactivation Date:2021-09-30
Deactivation Code:
Reactivation Date:2021-10-20
Provider Licenses
StateLicense IDTaxonomies
CAASW1032561041C0700X, 101YM0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program