Provider Demographics
NPI:1467917930
Name:RUTTER, SAMANTHA (RBT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:RUTTER
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 1:16800 DALLAS PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-1961
Mailing Address - Country:US
Mailing Address - Phone:940-300-7606
Mailing Address - Fax:
Practice Address - Street 1:1401 UNIVERSAL CITY BLVD
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78148-3317
Practice Address - Country:US
Practice Address - Phone:210-336-1524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-18-72701247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXRBT-18-72701OtherBACB