Provider Demographics
NPI:1215412085
Name:LEAHY, SAMANTHA (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:LEAHY
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16200 VENTURA BLVD STE 225
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4660
Mailing Address - Country:US
Mailing Address - Phone:818-369-4440
Mailing Address - Fax:
Practice Address - Street 1:16200 VENTURA BLVD STE 225
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4660
Practice Address - Country:US
Practice Address - Phone:818-369-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-18-32827103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1740732023OtherGROUP NPI