Healthcare Provider Details

I. General information

NPI: 1750230561
Provider Name (Legal Business Name): MARYAM SAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2026
Last Update Date: 01/26/2026
Certification Date: 01/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 BRIDLE RUN TER
ALPINE CA
91901-2631
US

IV. Provider business mailing address

215 BRIDLE RUN TER
ALPINE CA
91901-2631
US

V. Phone/Fax

Practice location:
  • Phone: 619-515-2300
  • Fax:
Mailing address:
  • Phone: 619-515-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number232748
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: