Provider Demographics
NPI:1235815606
Name:ROMERO, SAMARA JACKLYN
Entity Type:Individual
Prefix:
First Name:SAMARA
Middle Name:JACKLYN
Last Name:ROMERO
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 1:1079 SPACE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80915-3612
Mailing Address - Country:US
Mailing Address - Phone:719-372-5752
Mailing Address - Fax:719-372-5752
Practice Address - Street 1:1079 SPACE CENTER DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915-3612
Practice Address - Country:US
Practice Address - Phone:719-372-5752
Practice Address - Fax:719-372-5752
Is Sole Proprietor?:No
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician