Provider Demographics
NPI:1598488579
Name:SPACK, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:SPACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10121 SHEPHARD ST # 8-301
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33967-4800
Practice Address - Country:US
Practice Address - Phone:561-319-8255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-233179106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician