Provider Demographics
NPI:1609355809
Name:ST CLAIR, SAMARA NICOLE (BCABA)
Entity Type:Individual
Prefix:
First Name:SAMARA
Middle Name:NICOLE
Last Name:ST CLAIR
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:SAMARA
Other - Middle Name:NICOLE
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCABA
Mailing Address - Street 1:1314 RIVERLAND RD SE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-3610
Mailing Address - Country:US
Mailing Address - Phone:866-565-7222
Mailing Address - Fax:877-734-1914
Practice Address - Street 1:3024 FOREST HILLS CIR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2312
Practice Address - Country:US
Practice Address - Phone:866-565-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0-23-14848106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1609355809Medicaid