Healthcare Provider Details

I. General information

NPI: 1740522747
Provider Name (Legal Business Name): SAMUEL F HEREDIA H14040440950
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2013
Last Update Date: 06/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 POST OFFICE DR #F
APTOS CA
95003-3953
US

IV. Provider business mailing address

105 POST OFFICE DR #F
APTOS CA
95003-3953
US

V. Phone/Fax

Practice location:
  • Phone: 831-476-1747
  • Fax: 831-685-1703
Mailing address:
  • Phone: 831-476-1747
  • Fax: 831-685-1703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberH1404040950
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: