MEDICARE: CHANEL SAMANTHA SIMPSON

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	101YM0800X	Mental Health Counselor	AMFT113110	CA

General Provider Information

NPI Number	:	1750941688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANEL SAMANTHA SIMPSON

Provider Business Mailing Address
First Line	:	920 ATLANTIC AVE STE 101
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90813-4592
Country	:	US
Telephone Number	:	949-690-1037
Fax Number	:

Provider Business Practice Location Address
First Line	:	920 ATLANTIC AVE STE 101
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90813-4592
Country	:	US
Telephone Number	:	949-690-1037
Fax Number	:

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

Provider Enumeration Date	:	06/13/2019
Last Update Date	:	06/13/2019

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