Provider Demographics
NPI:1528568391
Name:CARDONA, SAMANTHA TANIA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:TANIA
Last Name:CARDONA
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 1:1815 W 213TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-2852
Mailing Address - Country:US
Mailing Address - Phone:310-328-0276
Mailing Address - Fax:
Practice Address - Street 1:1815 W 213TH ST STE 100
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-2852
Practice Address - Country:US
Practice Address - Phone:310-328-0276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-17
Last Update Date:2024-01-23
Deactivation Date:2023-12-01
Deactivation Code:
Reactivation Date:2024-01-23
Provider Licenses
StateLicense IDTaxonomies
CA25425225XP0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty