Provider Demographics
NPI:1154528461
Name:SAMUEL, NOSHEEN
Entity type:Individual
Prefix:
First Name:NOSHEEN
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:572 N ARROWHEAD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92401-1251
Mailing Address - Country:US
Mailing Address - Phone:909-266-2775
Mailing Address - Fax:909-266-2790
Practice Address - Street 1:572 N ARROWHEAD AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92401-1251
Practice Address - Country:US
Practice Address - Phone:909-266-2775
Practice Address - Fax:909-266-2790
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46426106H00000X
CA45170106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4015OtherSIMON STAFF NUMBER