Provider Demographics
NPI:1659645927
Name:SAMUDIO, MERCEDES (LCSW)
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:
Last Name:SAMUDIO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MERCEDES
Other - Middle Name:
Other - Last Name:STANLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:PO BOX 601
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-0601
Mailing Address - Country:US
Mailing Address - Phone:310-351-3609
Mailing Address - Fax:
Practice Address - Street 1:2930 W IMPERIAL HWY
Practice Address - Street 2:SUITE 310
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90303-3143
Practice Address - Country:US
Practice Address - Phone:310-351-3609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW32387101YM0800X, 104100000X
CALCS 646451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker