Provider Demographics
NPI:1669250718
Name:FERNANDEZ, SAMANTHA JOY
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:JOY
Last Name:FERNANDEZ
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 1:84 ROXBURY ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050-5845
Mailing Address - Country:US
Mailing Address - Phone:408-823-4199
Mailing Address - Fax:
Practice Address - Street 1:1811 GRAND CANAL BLVD STE 2
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8107
Practice Address - Country:US
Practice Address - Phone:877-418-2978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician