Provider Demographics
NPI:1841572153
Name:SOUN, SAM SAMNANG (BA)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:SAMNANG
Last Name:SOUN
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:SAMNANG
Other - Middle Name:SAM
Other - Last Name:SOUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:3353 BRADSHAW RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2607
Mailing Address - Country:US
Mailing Address - Phone:916-854-4564
Mailing Address - Fax:916-857-1580
Practice Address - Street 1:3353 BRADSHAW RD
Practice Address - Street 2:SUITE 106
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95827-2607
Practice Address - Country:US
Practice Address - Phone:916-854-4564
Practice Address - Fax:916-857-1580
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)