Healthcare Provider Details

I. General information

NPI: 1629508874
Provider Name (Legal Business Name): BRENDA SAMAYOA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 07/21/2022
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 E PACIFIC COAST HWY
LONG BEACH CA
90804
US

IV. Provider business mailing address

5150 E PACIFIC COAST HWY
LONG BEACH CA
90804-3312
US

V. Phone/Fax

Practice location:
  • Phone: 562-490-7600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number77467
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number101975
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: