Provider Demographics
NPI:1891277877
Name:DAVIS, SAMANTHA ELIZABETH (ACSW, CADC-CAS)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ELIZABETH
Last Name:DAVIS
Suffix:
Gender:F
Credentials:ACSW, CADC-CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:658 E BRIER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2847
Mailing Address - Country:US
Mailing Address - Phone:909-501-0705
Mailing Address - Fax:
Practice Address - Street 1:658 E BRIER DR STE 200
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2847
Practice Address - Country:US
Practice Address - Phone:909-501-0705
Practice Address - Fax:909-387-7611
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW118225104100000X
390200000X
CAC040930217101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAASW118225OtherBOARD OF BEHAVIORAL SCIENCES
CAC040930217OtherCALIFORNIA CONSORTIUM OF ADDICTION PROGRAMS AND PROFESSIONALS