Healthcare Provider Details

I. General information

NPI: 1215601679
Provider Name (Legal Business Name): SAMANTHA MORALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2021
Last Update Date: 08/08/2021
Certification Date: 08/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 E 61ST ST
LOS ANGELES CA
90001-1422
US

IV. Provider business mailing address

1730 E 61ST ST
LOS ANGELES CA
90001-1422
US

V. Phone/Fax

Practice location:
  • Phone: 909-519-2936
  • Fax:
Mailing address:
  • Phone: 909-519-2936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: