Healthcare Provider Details

I. General information

NPI: 1720583461
Provider Name (Legal Business Name): RON MATHEW SAMAAN LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 06/29/2020
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W ROUTE 66 STE 202
GLENDORA CA
91740-4335
US

IV. Provider business mailing address

415 W ROUTE 66 STE 202
GLENDORA CA
91740-4335
US

V. Phone/Fax

Practice location:
  • Phone: 626-963-4467
  • Fax: 626-963-9543
Mailing address:
  • Phone: 626-963-4467
  • Fax: 626-963-9543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number119273
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: