Basic Information
| Provider Information | |||||||||
| NPI: | 1861014896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMADIAN | ||||||||
| FirstName: | SOPHIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M. ED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2501 PENDLETON DR APT 1608 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730723468 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2617 GENERAL PERSHING BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731076437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058582700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2020 | ||||||||
| LastUpdateDate: | 05/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 03061996 | 05 | OK | MEDICAID |