Healthcare Provider Details

I. General information

NPI: 1710429022
Provider Name (Legal Business Name): MAYRA JEANETTE SAMANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2016
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2677 N MAIN ST STE 110
SANTA ANA CA
92705-6663
US

IV. Provider business mailing address

803 B ST APT 1
EUREKA CA
95501-1780
US

V. Phone/Fax

Practice location:
  • Phone: 714-274-7577
  • Fax:
Mailing address:
  • Phone: 661-404-6020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT104726
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT140156
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: