Healthcare Provider Details

I. General information

NPI: 1114530144
Provider Name (Legal Business Name): SAMUEL ZAVALA ACSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 BIRCH ST STE 3000
NEWPORT BEACH CA
92660-2140
US

IV. Provider business mailing address

2268 DELTA AVE
LONG BEACH CA
90810-3530
US

V. Phone/Fax

Practice location:
  • Phone: 877-421-1711
  • Fax: 949-576-3913
Mailing address:
  • Phone: 562-507-6560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number96539
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: