Basic Information
| Provider Information | |||||||||
| NPI: | 1790265387 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAAF | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANDREWS | ||||||||
| OtherFirstName: | SAMANTHA | ||||||||
| OtherMiddleName: | RAE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1350 3RD ST | ||||||||
| Address2: | |||||||||
| City: | LA VERNE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917505201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095365921 | ||||||||
| FaxNumber: | 9095963954 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 3RD ST | ||||||||
| Address2: | |||||||||
| City: | LA VERNE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917505201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095965921 | ||||||||
| FaxNumber: | 9095963954 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2018 | ||||||||
| LastUpdateDate: | 08/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | PT38265 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.