Provider Demographics
NPI:1861160178
Name:VIVEROS, SAMANTHA JEAN (BA, AAC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JEAN
Last Name:VIVEROS
Suffix:
Gender:F
Credentials:BA, AAC
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:JEAN
Other - Last Name:COY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4526 FEDERAL AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-2132
Mailing Address - Country:US
Mailing Address - Phone:425-349-6200
Mailing Address - Fax:
Practice Address - Street 1:4526 FEDERAL AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2132
Practice Address - Country:US
Practice Address - Phone:425-349-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61220936101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor