Provider Demographics
NPI:1124501309
Name:VALLE, SAMANTHA (CP60641068)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:VALLE
Suffix:
Gender:F
Credentials:CP60641068
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34713 2ND LN S APT K134
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8719
Mailing Address - Country:US
Mailing Address - Phone:509-750-3859
Mailing Address - Fax:
Practice Address - Street 1:515 W HARRISON ST STE 109
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-4403
Practice Address - Country:US
Practice Address - Phone:206-226-9435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60641068101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)