MEDICARE: SAMANTHA NEMIROV

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LPCC22217	CA

General Provider Information

NPI Number	:	1124828843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA NEMIROV

Provider Business Mailing Address
First Line	:	3288 5TH AVE APT 323
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-5751
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4241 JUTLAND DR STE 207
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-3653
Country	:	US
Telephone Number	:	619-733-6414
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2025
Last Update Date	:	03/15/2026

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