Healthcare Provider Details

I. General information

NPI: 1902719750
Provider Name (Legal Business Name): SAMANTHA HERNANDEZ GUTIERREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S SEPULVEDA BLVD
LOS ANGELES CA
90049-3540
US

IV. Provider business mailing address

3949 1/2 W 111TH PL
INGLEWOOD CA
90303-2643
US

V. Phone/Fax

Practice location:
  • Phone: 323-303-6078
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: