Provider Demographics
NPI:1740800796
Name:FOOTE, SAMANTHA (MT-BC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:FOOTE
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 N CAPE COD AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-4440
Mailing Address - Country:US
Mailing Address - Phone:208-906-3875
Mailing Address - Fax:
Practice Address - Street 1:2924 N CAPE COD AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-4440
Practice Address - Country:US
Practice Address - Phone:208-906-3875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician