Provider Demographics
NPI:1003575366
Name:WEBER, SAMUEL DOUGLAS
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:DOUGLAS
Last Name:WEBER
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 1:720 S 5TH AVE APT 10
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85701-2753
Mailing Address - Country:US
Mailing Address - Phone:414-217-8560
Mailing Address - Fax:
Practice Address - Street 1:2230 E PRINCE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-2002
Practice Address - Country:US
Practice Address - Phone:520-461-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRBT-21-194304106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician