Provider Demographics
NPI:1730472721
Name:SAMPSON, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:SAMPSON
Suffix:
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 1:49 POWELL ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-2849
Mailing Address - Country:US
Mailing Address - Phone:415-644-0504
Mailing Address - Fax:415-644-0514
Practice Address - Street 1:995 MARKET ST
Practice Address - Street 2:7TH FLOOR
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-1702
Practice Address - Country:US
Practice Address - Phone:415-644-0507
Practice Address - Fax:415-644-0380
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor