Provider Demographics
NPI:1649748781
Name:SANDY-SINCLAIR, SAMANTHA NICOLE (BCBA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:NICOLE
Last Name:SANDY-SINCLAIR
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6291 E 5TH RD
Mailing Address - Street 2:
Mailing Address - City:WALSHVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62091-2023
Mailing Address - Country:US
Mailing Address - Phone:618-339-9303
Mailing Address - Fax:
Practice Address - Street 1:522 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MASCOUTAH
Practice Address - State:IL
Practice Address - Zip Code:62258-2240
Practice Address - Country:US
Practice Address - Phone:618-566-0313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-21-53611103K00000X
ILRBT-18-69413106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst