Provider Demographics
NPI:1689206310
Name:BASS, SAMANTHA (RBT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BASS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 GULF BREEZE PKWY
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-3350
Mailing Address - Country:US
Mailing Address - Phone:800-676-5130
Mailing Address - Fax:
Practice Address - Street 1:3208 GULF BREEZE PKWY
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32563-3350
Practice Address - Country:US
Practice Address - Phone:800-676-5130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB200-792-79-685-0OtherDRIVER'S LICENSE