Provider Demographics
NPI:1437826260
Name:PAITSEL, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:PAITSEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 RIDGECREST DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-6239
Mailing Address - Country:US
Mailing Address - Phone:540-892-4271
Mailing Address - Fax:
Practice Address - Street 1:921 RIDGECREST DR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-6239
Practice Address - Country:US
Practice Address - Phone:540-892-4271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-28
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-21-169438106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
VARBT-21-169438Medicaid