Healthcare Provider Details

I. General information

NPI: 1770310161
Provider Name (Legal Business Name): SAMANTHA KINNISON LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 E KATELLA AVE STE 625
ANAHEIM CA
92806-5995
US

IV. Provider business mailing address

3321 N BUFFALO DR STE 225
LAS VEGAS NV
89129-6678
US

V. Phone/Fax

Practice location:
  • Phone: 800-577-4701
  • Fax:
Mailing address:
  • Phone: 702-857-8800
  • Fax: 702-857-8801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number13771
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: