Provider Demographics
NPI:1386897502
Name:SAMUELS, MARY ROANNE DE GUIA (LMFT)
Entity type:Individual
Prefix:
First Name:MARY ROANNE
Middle Name:DE GUIA
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:ROANNE
Other - Last Name:SAMUELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:704 PLACER CIRCLE
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687
Mailing Address - Country:US
Mailing Address - Phone:707-384-2815
Mailing Address - Fax:
Practice Address - Street 1:704 PLACER CIRCLE
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687
Practice Address - Country:US
Practice Address - Phone:707-384-2815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-31
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56303106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist