Provider Demographics
NPI:1477118735
Name:PASKO, SAMUEL GRANGER
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:GRANGER
Last Name:PASKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1738 S TREMONT ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-5309
Mailing Address - Country:US
Mailing Address - Phone:760-439-2800
Mailing Address - Fax:
Practice Address - Street 1:1738 S TREMONT ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-5309
Practice Address - Country:US
Practice Address - Phone:760-439-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2024-10-02
Deactivation Date:2024-09-16
Deactivation Code:
Reactivation Date:2024-09-26
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CAAMFT146376106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician