Healthcare Provider Details

I. General information

NPI: 1609345958
Provider Name (Legal Business Name): SAMANTHA LUU HEREDIA OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA LUU OTD, OTR/L

II. Dates (important events)

Enumeration Date: 11/15/2018
Last Update Date: 03/14/2024
Certification Date: 03/14/2024
Deactivation Date: 08/01/2022
Reactivation Date: 09/15/2022

III. Provider practice location address

2500 REDHILL AVE STE 100
SANTA ANA CA
92705-5518
US

IV. Provider business mailing address

2700 PETERSON PL APT 33C
COSTA MESA CA
92626-5347
US

V. Phone/Fax

Practice location:
  • Phone: 949-748-8571
  • Fax:
Mailing address:
  • Phone: 323-379-6711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number23885
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: