Healthcare Provider Details

I. General information

NPI: 1093628562
Provider Name (Legal Business Name): SAMANTHA SHEYLA GENOVEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18726 S WESTERN AVE STE 120
GARDENA CA
90248-3831
US

IV. Provider business mailing address

1105 S TAMARIND AVE
COMPTON CA
90220-4819
US

V. Phone/Fax

Practice location:
  • Phone: 323-433-4165
  • Fax:
Mailing address:
  • Phone: 323-433-4165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: