Healthcare Provider Details

I. General information

NPI: 1912787516
Provider Name (Legal Business Name): ANTOINETTE SAMORA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7286 S YOSEMITE ST
CENTENNIAL CO
80112-2204
US

IV. Provider business mailing address

7286 S YOSEMITE ST
CENTENNIAL CO
80112-2204
US

V. Phone/Fax

Practice location:
  • Phone: 303-824-5866
  • Fax:
Mailing address:
  • Phone: 303-824-5866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACA.0008285
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: