Provider Demographics
NPI:1043968266
Name:ADRASSE, SAMANTHA DIEDRE (RBT-21-168594)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:DIEDRE
Last Name:ADRASSE
Suffix:
Gender:F
Credentials:RBT-21-168594
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27844 MANOR OAK DR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-5367
Mailing Address - Country:US
Mailing Address - Phone:754-422-4791
Mailing Address - Fax:
Practice Address - Street 1:27844 MANOR OAK DR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-5367
Practice Address - Country:US
Practice Address - Phone:754-422-4791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-16
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-168594106S00000X
FL222Q00000X
FLSI55942355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110674100Medicaid