Healthcare Provider Details

I. General information

NPI: 1851656052
Provider Name (Legal Business Name): SAMUAL VINEY MFTI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2012
Last Update Date: 04/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3657 GOLDENSTAR ST
PLUMAS LAKE CA
95961-8746
US

IV. Provider business mailing address

3657 GOLDENSTAR ST
PLUMAS LAKE CA
95961-8746
US

V. Phone/Fax

Practice location:
  • Phone: 916-475-8590
  • Fax: 916-441-8013
Mailing address:
  • Phone: 916-475-8590
  • Fax: 916-441-8013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberR0452060
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: