Healthcare Provider Details

I. General information

NPI: 1417653429
Provider Name (Legal Business Name): SAMANTHA KIYA MAE KOYAMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2023
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

494 BLOSSOM WAY
CHERRYLAND CA
94541-1948
US

IV. Provider business mailing address

494 BLOSSOM WAY
CHERRYLAND CA
94541-1948
US

V. Phone/Fax

Practice location:
  • Phone: 510-315-0314
  • Fax: 510-582-9080
Mailing address:
  • Phone: 510-315-0314
  • Fax: 510-582-9080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW117443
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: