Provider Demographics
NPI:1578080933
Name:TAKAZATO, SAMANTA ANNE (MED, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:SAMANTA
Middle Name:ANNE
Last Name:TAKAZATO
Suffix:
Gender:F
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 WINDHAM CT BLDG G
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-3195
Mailing Address - Country:US
Mailing Address - Phone:240-222-2699
Mailing Address - Fax:
Practice Address - Street 1:2715 MACKEY PL STE 230
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-2544
Practice Address - Country:US
Practice Address - Phone:318-779-1397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-27
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-648103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst