Provider Demographics
NPI:1295422921
Name:POLEY, SAMANTHA MARIE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:POLEY
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 1:38090 CYPRESS POINT DR
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-5823
Mailing Address - Country:US
Mailing Address - Phone:858-254-0216
Mailing Address - Fax:
Practice Address - Street 1:790 S STATE ST STE 6
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-4924
Practice Address - Country:US
Practice Address - Phone:951-654-6002
Practice Address - Fax:951-612-8195
Is Sole Proprietor?:No
Enumeration Date:2023-04-21
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 172V00000X
CAMPSS-LZXODB175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker