Provider Demographics
NPI:1043645468
Name:WEISS, SAM
Entity type:Individual
Prefix:MR
First Name:SAM
Middle Name:
Last Name:WEISS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6147 IBBETSON AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90713-1043
Mailing Address - Country:US
Mailing Address - Phone:949-478-5062
Mailing Address - Fax:
Practice Address - Street 1:6147 IBBETSON AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90713-1043
Practice Address - Country:US
Practice Address - Phone:949-478-5062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-04
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA865901041C0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program