Provider Demographics
NPI:1275367583
Name:AGRICOLA, SAMANTHA S
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:S
Last Name:AGRICOLA
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 1:5815 WRIGHTCREST DR
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-3050
Mailing Address - Country:US
Mailing Address - Phone:310-780-7395
Mailing Address - Fax:
Practice Address - Street 1:1000 QUAIL ST STE 170
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2765
Practice Address - Country:US
Practice Address - Phone:714-900-3370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133092106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist