Provider Demographics
NPI:1386778751
Name:SAMUELSON, MICHELLE CORENNE (LMFT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:CORENNE
Last Name:SAMUELSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:CORENNE
Other - Last Name:SCALES/ SANDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3435 E THOUSAND OAKS BLVD UNIT 7814
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91359-8054
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1446 CALLE VIOLETA
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-6735
Practice Address - Country:US
Practice Address - Phone:757-805-3409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51738106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist