Healthcare Provider Details

I. General information

NPI: 1427826791
Provider Name (Legal Business Name): SAMANTHA MARLENE WILLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KOLE WILLIS

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W KIMBERLY AVE STE 220
PLACENTIA CA
92870-6314
US

IV. Provider business mailing address

701 W KIMBERLY AVE STE 220
PLACENTIA CA
92870-6314
US

V. Phone/Fax

Practice location:
  • Phone: 833-879-4274
  • Fax:
Mailing address:
  • Phone:
  • Fax: 714-879-2274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: