MEDICARE: SAMANTHA PERSOFF

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	1041C0700X	Clinical Social Worker	21991	CA

General Provider Information

NPI Number	:	1659829083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA PERSOFF

Provider Business Mailing Address
First Line	:	12620 ADMIRAL AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-6510
Country	:	US
Telephone Number	:	818-203-1777
Fax Number	:	424-227-7056

Provider Business Practice Location Address
First Line	:	12620 ADMIRAL AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-6510
Country	:	US
Telephone Number	:	818-203-1777
Fax Number	:	424-227-7056

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

Provider Enumeration Date	:	09/14/2016
Last Update Date	:	09/14/2016

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Directions to “ SAMANTHA PERSOFF ” Practice Location

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