Healthcare Provider Details

I. General information

NPI: 1285385294
Provider Name (Legal Business Name): ALEXANDRA SAMARAH ESPITIA MARTINEZ RADT I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 01/08/2024
Certification Date: 01/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7592 BROADWAY
LEMON GROVE CA
91945-1604
US

IV. Provider business mailing address

1750 5TH AVE
SAN DIEGO CA
92101-2754
US

V. Phone/Fax

Practice location:
  • Phone: 619-515-2550
  • Fax:
Mailing address:
  • Phone: 619-362-9905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1477240822
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: