Healthcare Provider Details

I. General information

NPI: 1316675697
Provider Name (Legal Business Name): SAMANTHA PROCHNOW ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2022
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 ATLANTIC AVE
LONG BEACH CA
90806-1701
US

IV. Provider business mailing address

396 TERRAINE AVE
LONG BEACH CA
90814-1914
US

V. Phone/Fax

Practice location:
  • Phone: 562-933-2000
  • Fax:
Mailing address:
  • Phone: 562-277-3080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103845
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: