Healthcare Provider Details

I. General information

NPI: 1285259051
Provider Name (Legal Business Name): MOLLY MECHAMMIL SAMAAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2020
Last Update Date: 08/11/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11900 W OLYMPIC BLVD STE 410
LOS ANGELES CA
90064-1168
US

IV. Provider business mailing address

11900 W OLYMPIC BLVD STE 410
LOS ANGELES CA
90064-1168
US

V. Phone/Fax

Practice location:
  • Phone: 888-225-1995
  • Fax:
Mailing address:
  • Phone: 888-225-1995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number33762
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: