=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639694722
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA SACKS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2017
-----------------------------------------------------
Last Update Date | 09/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30851 AGOURA RD STE 202
-----------------------------------------------------
City | AGOURA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91301-4344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-384-6083
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4768 PARK GRANADA STE 109A
-----------------------------------------------------
City | CALABASAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91302-3312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-384-6083
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC40908
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------