Provider Demographics
NPI:1790265387
Name:GRAAF, SAMANTHA (LPT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GRAAF
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:RAE
Other - Last Name:ANDREWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1350 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-5201
Mailing Address - Country:US
Mailing Address - Phone:909-536-5921
Mailing Address - Fax:909-596-3954
Practice Address - Street 1:1350 3RD ST
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-5201
Practice Address - Country:US
Practice Address - Phone:909-596-5921
Practice Address - Fax:909-596-3954
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT38265167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician