Basic Information
Provider Information | |||||||||
NPI: | 1083928840 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROOT | ||||||||
FirstName: | SAMUEL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17701 SAN PASQUAL VALLEY RD | ||||||||
Address2: |   | ||||||||
City: | ESCONDIDO | ||||||||
State: | CA | ||||||||
PostalCode: | 920255301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7607414300 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 17701 SAN PASQUAL VALLEY RD | ||||||||
Address2: |   | ||||||||
City: | ESCONDIDO | ||||||||
State: | CA | ||||||||
PostalCode: | 920255301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7607414300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/03/2010 | ||||||||
LastUpdateDate: | 08/03/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 61623 | CA | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.