Provider Demographics
NPI:1255031803
Name:SAMS, JUANITA LATRICE
Entity type:Individual
Prefix:
First Name:JUANITA
Middle Name:LATRICE
Last Name:SAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 CAMINO DEL RIO S STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3505
Mailing Address - Country:US
Mailing Address - Phone:619-381-7748
Mailing Address - Fax:
Practice Address - Street 1:2970 MARKET ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-3241
Practice Address - Country:US
Practice Address - Phone:619-236-9492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-03
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-WSBQPY175T00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist