Provider Demographics
NPI:1467050831
Name:SAMUELSON, MICHAEL JOSEPH
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:SAMUELSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19712 MACARTHUR BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-2407
Mailing Address - Country:US
Mailing Address - Phone:949-670-2203
Mailing Address - Fax:
Practice Address - Street 1:19712 MACARTHUR BLVD STE 110
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-2407
Practice Address - Country:US
Practice Address - Phone:949-670-2203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-16
Last Update Date:2025-02-10
Deactivation Date:2021-09-30
Deactivation Code:
Reactivation Date:2021-10-20
Provider Licenses
StateLicense IDTaxonomies
CALCSW1271291041C0700X
390200000X
CAASW103256101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program