Provider Demographics
NPI:1457058778
Name:SAMPLE, MARY ABIGAIL
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ABIGAIL
Last Name:SAMPLE
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 1:123 W GUTIERREZ ST
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101-3424
Mailing Address - Country:US
Mailing Address - Phone:805-705-6485
Mailing Address - Fax:
Practice Address - Street 1:123 W GUTIERREZ ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93101-3424
Practice Address - Country:US
Practice Address - Phone:805-705-6485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical