Provider Demographics
NPI:1437745429
Name:BUCK, SAMANTHA RAEANNA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RAEANNA
Last Name:BUCK
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 1:10969 W LOMA LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-0403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5656 S POWER RD STE 115
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-8480
Practice Address - Country:US
Practice Address - Phone:480-773-4511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2022-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
AZRBT-21-155526106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician