Provider Demographics
NPI:1639702210
Name:ANTHONY, SAMANTHA JEAN (RAD1)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JEAN
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:RAD1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3148 MIDWAY DR # 113
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4539
Mailing Address - Country:US
Mailing Address - Phone:619-363-0853
Mailing Address - Fax:619-362-9905
Practice Address - Street 1:3148 MIDWAY DR # 113
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4539
Practice Address - Country:US
Practice Address - Phone:619-363-0853
Practice Address - Fax:619-362-9905
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor