Healthcare Provider Details

I. General information

NPI: 1194637470
Provider Name (Legal Business Name): SAMANTHA GREENE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S BRAND BLVD STE 110
SAN FERNANDO CA
91340-4039
US

IV. Provider business mailing address

601 S BRAND BLVD STE 110
SAN FERNANDO CA
91340-4039
US

V. Phone/Fax

Practice location:
  • Phone: 818-714-2275
  • Fax: 818-279-0784
Mailing address:
  • Phone: 818-714-2275
  • Fax: 818-279-0784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: