Healthcare Provider Details

I. General information

NPI: 1902753460
Provider Name (Legal Business Name): SAMANTHA DANIELLE MERLOS EDS, PPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2026
Last Update Date: 03/13/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27400 HIGHWAY 18
LAKE ARROWHEAD CA
92352
US

IV. Provider business mailing address

16358 SAN JACINTO AVE
FONTANA CA
92336-1982
US

V. Phone/Fax

Practice location:
  • Phone: 909-336-2038
  • Fax:
Mailing address:
  • Phone: 909-454-4891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: