Provider Demographics
NPI:1629428693
Name:SALGADO, SAMUEL JR
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:SALGADO
Suffix:JR
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 1:2275 S MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-5303
Mailing Address - Country:US
Mailing Address - Phone:951-279-3222
Mailing Address - Fax:
Practice Address - Street 1:17130 SEQUOIA ST STE 204
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1827
Practice Address - Country:US
Practice Address - Phone:951-205-9370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-20
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT110703106H00000X
CAIMF92744106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist