Healthcare Provider Details

I. General information

NPI: 1952709719
Provider Name (Legal Business Name): BOBBY SAMPSON ACSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2014
Last Update Date: 12/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 REDONDO AVE
LONG BEACH CA
90806-2325
US

IV. Provider business mailing address

2600 REDONDO AVE
LONG BEACH CA
90806-2325
US

V. Phone/Fax

Practice location:
  • Phone: 562-256-7920
  • Fax:
Mailing address:
  • Phone: 562-256-7920
  • Fax:

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 Code1041C0700X
TaxonomyClinical Social Worker
License Number80798
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: