Provider Demographics
NPI:1215409362
Name:KLASEK, SAMANTHA NICOLE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:NICOLE
Last Name:KLASEK
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 1:390 UNION BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-6514
Mailing Address - Country:US
Mailing Address - Phone:303-989-8172
Mailing Address - Fax:303-984-4366
Practice Address - Street 1:390 UNION BLVD STE 300
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-6514
Practice Address - Country:US
Practice Address - Phone:720-534-4221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-18-33457103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst