Healthcare Provider Details

I. General information

NPI: 1891277877
Provider Name (Legal Business Name): SAMANTHA ELIZABETH DAVIS ACSW, CADC-CAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2018
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

658 E BRIER DR STE 200
SAN BERNARDINO CA
92408-2847
US

IV. Provider business mailing address

658 E BRIER DR STE 200
SAN BERNARDINO CA
92408-2847
US

V. Phone/Fax

Practice location:
  • Phone: 909-501-0705
  • Fax: 909-387-7611
Mailing address:
  • Phone: 909-501-0705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC040930217
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW118225
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: