Healthcare Provider Details

I. General information

NPI: 1770287971
Provider Name (Legal Business Name): SAMUEL JOSEPH VARY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2023
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 N MARENGO AVE
PASADENA CA
91103-2217
US

IV. Provider business mailing address

1230 N MARENGO AVE
PASADENA CA
91103-2217
US

V. Phone/Fax

Practice location:
  • Phone: 626-797-1124
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1489271122
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: