Provider Demographics
NPI:1114437548
Name:DAVIS, SAMANTHA LEE (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:LEE
Other - Last Name:HARTLESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22641 FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-9117
Mailing Address - Country:US
Mailing Address - Phone:501-547-3053
Mailing Address - Fax:
Practice Address - Street 1:22461 I-30 FRONTAGE RD
Practice Address - Street 2:1100B
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72022
Practice Address - Country:US
Practice Address - Phone:501-574-3053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAC-022106E00000X
1-18-31009103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst