Provider Demographics
NPI:1801160700
Name:SAMUEL, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:SAMUEL
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 1:147 S 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91746-2914
Mailing Address - Country:US
Mailing Address - Phone:626-968-0791
Mailing Address - Fax:626-968-0091
Practice Address - Street 1:147 S 6TH AVE
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91746-2914
Practice Address - Country:US
Practice Address - Phone:626-968-0791
Practice Address - Fax:626-968-0091
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101Y00000XOtherSOCIAL & HUMAN SERVICES