Basic Information
Provider Information | |||||||||
NPI: | 1841572153 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SOUN | ||||||||
FirstName: | SAM | ||||||||
MiddleName: | SAMNANG | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | BA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SOUN | ||||||||
OtherFirstName: | SAMNANG | ||||||||
OtherMiddleName: | SAM | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | BA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3353 BRADSHAW RD | ||||||||
Address2: | SUITE 106 | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958272607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9168544564 | ||||||||
FaxNumber: | 9168571580 | ||||||||
Practice Location | |||||||||
Address1: | 3353 BRADSHAW RD | ||||||||
Address2: | SUITE 106 | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958272607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9168544564 | ||||||||
FaxNumber: | 9168571580 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2011 | ||||||||
LastUpdateDate: | 09/13/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   | CA | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.