Healthcare Provider Details

I. General information

NPI: 1447788989
Provider Name (Legal Business Name): SAMARA YAEL CARDONA ESPINOZA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2017
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 W RAMSEY ST # 100
BANNING CA
92220-4477
US

IV. Provider business mailing address

PO BOX 172
RIVERSIDE CA
92502-0172
US

V. Phone/Fax

Practice location:
  • Phone: 951-849-7142
  • Fax:
Mailing address:
  • Phone: 760-289-0611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number106274
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: