Provider Demographics
NPI:1275167280
Name:NELSON, SAMANTHA B (MED, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:B
Last Name:NELSON
Suffix:
Gender:F
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 RED STONE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-2332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 LIBERTY RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-4319
Practice Address - Country:US
Practice Address - Phone:859-447-2309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-28
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133003441103K00000X
KY273595103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst