Provider Demographics
NPI:1609345958
Name:HEREDIA, SAMANTHA LUU (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LUU
Last Name:HEREDIA
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:DR
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:LUU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTD, OTR/L
Mailing Address - Street 1:2700 PETERSON PL APT 33C
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5347
Mailing Address - Country:US
Mailing Address - Phone:323-379-6711
Mailing Address - Fax:
Practice Address - Street 1:2500 REDHILL AVE STE 100
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5518
Practice Address - Country:US
Practice Address - Phone:949-748-8571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2024-03-14
Deactivation Date:2022-08-01
Deactivation Code:
Reactivation Date:2022-09-15
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA23885225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician