Basic Information
| Provider Information | |||||||||
| NPI: | 1770530974 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMANO | ||||||||
| FirstName: | ITALO | ||||||||
| MiddleName: | AUGUSTO | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3019 FALL WAY DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782473233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104956346 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4242 MEDICAL DR | ||||||||
| Address2: | SUITE 6300 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782295640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106148400 | ||||||||
| FaxNumber: | 2106148165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 09/12/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 23724 | TX | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 151188301 | 01 | TX | MEDICAID GROUP | OTHER | 128813606 | 05 | TX | MEDICAID | 01-0624198 | 01 | TX | TAX ID # FOR GROUP | OTHER |