Provider Demographics
NPI:1376283143
Name:WIDDER, SAMANTHA (RBT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WIDDER
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 CLOISTER AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44709-1242
Mailing Address - Country:US
Mailing Address - Phone:330-933-2397
Mailing Address - Fax:
Practice Address - Street 1:3720 DRESSLER RD NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2700
Practice Address - Country:US
Practice Address - Phone:330-309-3133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician