Provider Demographics
NPI:1487376380
Name:URENA, SAMANTHA MARIE (1041C0700X)
Entity type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:MARIE
Last Name:URENA
Suffix:
Gender:F
Credentials:1041C0700X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1010
Mailing Address - Country:US
Mailing Address - Phone:818-630-7480
Mailing Address - Fax:
Practice Address - Street 1:805 N CENTRAL AVE UNIT 200
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1230
Practice Address - Country:US
Practice Address - Phone:818-630-7480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-16
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X390200000X
CAASW1271591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program