Provider Demographics
NPI:1790197176
Name:SAM, JEANNINE (BCBA)
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:
Last Name:SAM
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 1:16 BLACKBERRY RD
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06811-3815
Mailing Address - Country:US
Mailing Address - Phone:203-312-3974
Mailing Address - Fax:
Practice Address - Street 1:16 BLACKBERRY RD
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06811-3815
Practice Address - Country:US
Practice Address - Phone:203-312-3974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-14-15457103K00000X
NY1139409174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174400000XOther Service ProvidersSpecialist