Provider Demographics
NPI:1962557900
Name:SAM, SIDARY (MSW)
Entity type:Individual
Prefix:MR
First Name:SIDARY
Middle Name:
Last Name:SAM
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:MR
Other - First Name:SIDARY
Other - Middle Name:
Other - Last Name:SAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4510 E PACIFIC COAST HWY STE 600
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-6914
Mailing Address - Country:US
Mailing Address - Phone:562-346-1100
Mailing Address - Fax:
Practice Address - Street 1:4510 E PACIFIC COAST HWY STE 600
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-6914
Practice Address - Country:US
Practice Address - Phone:562-346-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW 22278101YM0800X
390200000X
CALCSW940131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program