Provider Demographics
NPI:1710440565
Name:AHL, SAMANTHA ELYSE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ELYSE
Last Name:AHL
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 1:4217 ALANDIA CT
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-2101
Mailing Address - Country:US
Mailing Address - Phone:805-657-8721
Mailing Address - Fax:
Practice Address - Street 1:400 W VENTURA BLVD STE 230
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-9142
Practice Address - Country:US
Practice Address - Phone:858-264-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician