Healthcare Provider Details

I. General information

NPI: 1982002325
Provider Name (Legal Business Name): SAMANTHA LEVY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2014
Last Update Date: 12/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 PELHAM AVE
LOS ANGELES CA
90064-2211
US

IV. Provider business mailing address

2305 PELHAM AVE
LOS ANGELES CA
90064-2211
US

V. Phone/Fax

Practice location:
  • Phone: 310-845-6046
  • Fax:
Mailing address:
  • Phone: 310-845-6046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: SAMANTHA ROBIN LEVY
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PH.D.
Phone: 310-845-6046