Basic Information
| Provider Information | |||||||||
| NPI: | 1790903847 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAM | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200S WELLS RD 200 | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930041377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056591740 | ||||||||
| FaxNumber: | 8056593217 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 S WELLS RD | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930041377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056591740 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 08/28/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCS23688 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.