Provider Demographics
NPI:1497107320
Name:SAMELSON, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:SAMELSON
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 1:3671 BUSINESS DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95820-2165
Mailing Address - Country:US
Mailing Address - Phone:916-402-4164
Mailing Address - Fax:
Practice Address - Street 1:3671 BUSINESS DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-2165
Practice Address - Country:US
Practice Address - Phone:916-402-4164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-02
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF101351106H00000X
CA121952106H00000X
390200000X
CALMFT121952106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program