Provider Demographics
NPI:1982242137
Name:BORGES, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BORGES
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 1:19582 MEADOW VIEW DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:95258-9338
Mailing Address - Country:US
Mailing Address - Phone:209-224-7389
Mailing Address - Fax:
Practice Address - Street 1:1305 E VINE ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-3179
Practice Address - Country:US
Practice Address - Phone:209-224-7389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-18
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
CA133577106H00000X
CA115249106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist