Provider Demographics
NPI:1164825048
Name:HORMAZA, SAMANTHA (MS)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:HORMAZA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13815 DEVAN LEE DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-5868
Mailing Address - Country:US
Mailing Address - Phone:904-412-8544
Mailing Address - Fax:
Practice Address - Street 1:13815 DEVAN LEE DR E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32226-5868
Practice Address - Country:US
Practice Address - Phone:904-412-8544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-06
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-18-33413103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst