Provider Demographics
NPI:1316165970
Name:ANTRAM, SAMUEL ROBERT (MFT)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:ROBERT
Last Name:ANTRAM
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2480 ROSEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-4023
Mailing Address - Country:US
Mailing Address - Phone:650-872-2760
Mailing Address - Fax:
Practice Address - Street 1:510 BROADWAY
Practice Address - Street 2:SUITE 201
Practice Address - City:MILLBRAE
Practice Address - State:CA
Practice Address - Zip Code:94030-1966
Practice Address - Country:US
Practice Address - Phone:650-302-5020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC33965106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist