=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790577450
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENDA MARIE SAMOWSKI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2025
-----------------------------------------------------
Last Update Date | 05/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 678 ADMIRAL ST
-----------------------------------------------------
City | MOSS BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94038-9629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-378-1930
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 678 ADMIRAL ST
-----------------------------------------------------
City | MOSS BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94038-9629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-378-1930
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 11793
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------