Healthcare Provider Details

I. General information

NPI: 1487376380
Provider Name (Legal Business Name): SAMANTHA MARIE URENA 1041C0700X
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2022
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 N CENTRAL AVE UNIT 200
GLENDALE CA
91203-1230
US

IV. Provider business mailing address

313 E BROADWAY
GLENDALE CA
91205-1010
US

V. Phone/Fax

Practice location:
  • Phone: 818-630-7480
  • Fax:
Mailing address:
  • Phone: 818-630-7480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW127159
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number390200000X
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: