Provider Demographics
NPI:1467087395
Name:MUNSON, SAMANTHA OTHENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:OTHENE
Last Name:MUNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11990 SAN VICENTE BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-6608
Mailing Address - Country:US
Mailing Address - Phone:805-601-6055
Mailing Address - Fax:
Practice Address - Street 1:337 RENNIE AVE APT D
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-6601
Practice Address - Country:US
Practice Address - Phone:917-880-3305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31513103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist