Provider Demographics
NPI:1902923873
Name:MULEMBO, SAMUEL W
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:W
Last Name:MULEMBO
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 1:2650 E DEL MAR BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-4817
Mailing Address - Country:US
Mailing Address - Phone:626-579-8087
Mailing Address - Fax:
Practice Address - Street 1:902 S MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-3427
Practice Address - Country:US
Practice Address - Phone:626-303-1541
Practice Address - Fax:626-599-9928
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10165103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9594126299OtherTAX ID