Healthcare Provider Details

I. General information

NPI: 1477042414
Provider Name (Legal Business Name): SAMANTHA LOZANO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 SPRUCE ST STE 250
RIVERSIDE CA
92507-7429
US

IV. Provider business mailing address

9505 ARLINGTON AVE APT 6
RIVERSIDE CA
92503-1214
US

V. Phone/Fax

Practice location:
  • Phone: 760-815-9056
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-18-31997
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: