Provider Demographics
NPI:1902193998
Name:SAMPLES, GAYLE (MFT)
Entity Type:Individual
Prefix:DR
First Name:GAYLE
Middle Name:
Last Name:SAMPLES
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 W COVINA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3203
Mailing Address - Country:US
Mailing Address - Phone:909-599-5433
Mailing Address - Fax:909-706-3099
Practice Address - Street 1:1100 W COVINA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3203
Practice Address - Country:US
Practice Address - Phone:909-599-5433
Practice Address - Fax:909-706-3099
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC40871106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist