Healthcare Provider Details

I. General information

NPI: 1154528461
Provider Name (Legal Business Name): NOSHEEN SAMUEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 01/17/2021
Certification Date: 01/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

572 N ARROWHEAD AVE
SAN BERNARDINO CA
92401-1251
US

IV. Provider business mailing address

572 N ARROWHEAD AVE
SAN BERNARDINO CA
92401-1251
US

V. Phone/Fax

Practice location:
  • Phone: 909-266-2775
  • Fax: 909-266-2790
Mailing address:
  • Phone: 909-266-2775
  • Fax: 909-266-2790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number46426
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number45170
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: