Healthcare Provider Details

I. General information

NPI: 1922869213
Provider Name (Legal Business Name): SAMANTHA J SMALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2024
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6950 EL CAJON BLVD
SAN DIEGO CA
92115-1738
US

IV. Provider business mailing address

3113 SWEETWATER SPRINGS BLVD APT 55
SPRING VALLEY CA
91978-1557
US

V. Phone/Fax

Practice location:
  • Phone: 619-493-0077
  • Fax:
Mailing address:
  • Phone: 619-729-6163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSUDRC1-26378
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: