Provider Demographics
NPI:1679669667
Name:POLLOCK, SAMUAL T (LPT)
Entity Type:Individual
Prefix:
First Name:SAMUAL
Middle Name:T
Last Name:POLLOCK
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2013 CHARLE ST APT F
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-5508
Mailing Address - Country:US
Mailing Address - Phone:714-226-9888
Mailing Address - Fax:
Practice Address - Street 1:2569 W WOODLAND DR
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2608
Practice Address - Country:US
Practice Address - Phone:714-226-9888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALPT 29433167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician