Provider Demographics
NPI:1710439591
Name:VICKERY, SAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:VICKERY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5015 CANYON CREST DR STE 112
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-6020
Mailing Address - Country:US
Mailing Address - Phone:951-781-0510
Mailing Address - Fax:951-784-7711
Practice Address - Street 1:5015 CANYON CREST DR STE 112
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-6020
Practice Address - Country:US
Practice Address - Phone:951-781-0510
Practice Address - Fax:951-784-7711
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CALMFT14375106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health