Provider Demographics
NPI:1497319610
Name:KAPP, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KAPP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:JO
Other - Last Name:BULLARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5847 NE 122ND AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-1079
Mailing Address - Country:US
Mailing Address - Phone:971-339-7040
Mailing Address - Fax:
Practice Address - Street 1:5847 NE 122ND AVE STE 101
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-1079
Practice Address - Country:US
Practice Address - Phone:971-339-7040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
OR1-21-52165103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician