MEDICARE: SAMRA ASEFI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		CA

General Provider Information

NPI Number	:	1215469051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMRA ASEFI

Provider Business Mailing Address
First Line	:	9130 NOLAN ST APT 2043
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95758-7547
Country	:	US
Telephone Number	:	510-255-9204
Fax Number	:	916-442-2525

Provider Business Practice Location Address
First Line	:	9130 NOLAN ST APT 2043
Second Line	:
City	:	ELK GROVE
State	:	CA
Zip	:	95758-7547
Country	:	US
Telephone Number	:	510-255-9204
Fax Number	:	916-442-2525

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2017
Last Update Date	:	03/31/2017

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