MEDICARE: MISS SAMANTHA MARIE URENA 1041C0700X

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	390200000X	Student in an Organized Health Care Education/Training Program	390200000X	CA
2	1041C0700X	Clinical Social Worker	ASW127159	CA

General Provider Information

NPI Number	:	1487376380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS SAMANTHA MARIE URENA 1041C0700X

Provider Business Mailing Address
First Line	:	313 E BROADWAY
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91205-1010
Country	:	US
Telephone Number	:	818-630-7480
Fax Number	:

Provider Business Practice Location Address
First Line	:	805 N CENTRAL AVE UNIT 200
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91203-1230
Country	:	US
Telephone Number	:	818-630-7480
Fax Number	:

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

Provider Enumeration Date	:	09/16/2022
Last Update Date	:	11/13/2024

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