Healthcare Provider Details

I. General information

NPI: 1528568391
Provider Name (Legal Business Name): SAMANTHA TANIA CARDONA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2018
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date: 12/01/2023
Reactivation Date: 01/23/2024

III. Provider practice location address

1815 W 213TH ST STE 100
TORRANCE CA
90501-2852
US

IV. Provider business mailing address

1815 W 213TH ST STE 100
TORRANCE CA
90501-2852
US

V. Phone/Fax

Practice location:
  • Phone: 310-328-0276
  • Fax:
Mailing address:
  • Phone: 310-328-0276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number25425
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: