Provider Demographics
NPI:1578178562
Name:VAN ZANDT, SAMANTHA ELISE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ELISE
Last Name:VAN ZANDT
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:PO BOX 2262
Mailing Address - Street 2:
Mailing Address - City:SEWARD
Mailing Address - State:AK
Mailing Address - Zip Code:99664-2262
Mailing Address - Country:US
Mailing Address - Phone:814-651-3036
Mailing Address - Fax:
Practice Address - Street 1:302 RAILWAY AVE.
Practice Address - Street 2:
Practice Address - City:SEWARD
Practice Address - State:AK
Practice Address - Zip Code:99664
Practice Address - Country:US
Practice Address - Phone:907-422-1011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician