Provider Demographics
NPI:1740522747
Name:HEREDIA, SAMUEL F (H14040440950)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:F
Last Name:HEREDIA
Suffix:
Gender:M
Credentials:H14040440950
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 POST OFFICE DR
Mailing Address - Street 2:#F
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-3953
Mailing Address - Country:US
Mailing Address - Phone:831-476-1747
Mailing Address - Fax:831-685-1703
Practice Address - Street 1:105 POST OFFICE DR
Practice Address - Street 2:#F
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-3953
Practice Address - Country:US
Practice Address - Phone:831-476-1747
Practice Address - Fax:831-685-1703
Is Sole Proprietor?:No
Enumeration Date:2013-03-18
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAH1404040950101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA770488100OtherSOBRIETY WORKS