Provider Demographics
NPI:1154846160
Name:SMITH-SAMPSON, ROESHELLE
Entity Type:Individual
Prefix:
First Name:ROESHELLE
Middle Name:
Last Name:SMITH-SAMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 W PROFESSIONAL PARK CT STE 1
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3250
Mailing Address - Country:US
Mailing Address - Phone:270-777-9283
Mailing Address - Fax:270-777-9283
Practice Address - Street 1:31 PROFESSIONAL VILLAGE CIR
Practice Address - Street 2:
Practice Address - City:LADYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29907-1575
Practice Address - Country:US
Practice Address - Phone:843-371-1602
Practice Address - Fax:803-905-4431
Is Sole Proprietor?:No
Enumeration Date:2017-08-10
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRBT-17-37766106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician