Basic Information
| Provider Information | |||||||||
| NPI: | 1730423658 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAM | ||||||||
| FirstName: | PAULA PHALLA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S TUSTIN ST | ||||||||
| Address2: | BLDG. D | ||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928662550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142893936 | ||||||||
| FaxNumber: | 7142893938 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 VICTORIA ST | ||||||||
| Address2: | |||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926271995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9494331167 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2012 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | PT34503 | CA | N | Behavioral Health & Social Service Providers | Counselor | 163W00000X | 95167659 | CA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.