Healthcare Provider Details

I. General information

NPI: 1023856630
Provider Name (Legal Business Name): SAMANTHA MOREHEAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2024
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4181 RUFFIN RD STE 150
SAN DIEGO CA
92123-1876
US

IV. Provider business mailing address

1418 TWINING AVE
SAN DIEGO CA
92154-3848
US

V. Phone/Fax

Practice location:
  • Phone: 619-292-9490
  • Fax:
Mailing address:
  • Phone: 619-791-6675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1553820324
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-FWLYSU
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: