Healthcare Provider Details

I. General information

NPI: 1114485570
Provider Name (Legal Business Name): SAMANTHA TAN M.S. CCC-SLP, CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W VENTURA BLVD STE 150
CAMARILLO CA
93010-9140
US

IV. Provider business mailing address

12168 MONOGRAM AVE
GRANADA HILLS CA
91344-2609
US

V. Phone/Fax

Practice location:
  • Phone: 805-383-1497
  • Fax: 805-383-1498
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: