Healthcare Provider Details

I. General information

NPI: 1477118735
Provider Name (Legal Business Name): SAMUEL GRANGER PASKO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date: 09/16/2024
Reactivation Date: 09/26/2024

III. Provider practice location address

1738 S TREMONT ST
OCEANSIDE CA
92054-5309
US

IV. Provider business mailing address

1738 S TREMONT ST
OCEANSIDE CA
92054-5309
US

V. Phone/Fax

Practice location:
  • Phone: 760-439-2800
  • Fax:
Mailing address:
  • Phone: 760-439-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT146376
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: