Provider Demographics
NPI:1548736770
Name:DISALVO, SAMANTHA COLLEEN
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:COLLEEN
Last Name:DISALVO
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 1:1201 JAN AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-3440
Mailing Address - Country:US
Mailing Address - Phone:831-245-7592
Mailing Address - Fax:
Practice Address - Street 1:1101 S WINCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-3901
Practice Address - Country:US
Practice Address - Phone:408-654-9311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician