Provider Demographics
NPI:1891264958
Name:NOSSAMAN, SAMANTHA RENEE (MT-BC, LPMT)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:RENEE
Last Name:NOSSAMAN
Suffix:
Gender:F
Credentials:MT-BC, LPMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7170 S BRADEN AVE STE 195
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-6324
Mailing Address - Country:US
Mailing Address - Phone:918-280-0090
Mailing Address - Fax:
Practice Address - Street 1:7170 S BRADEN AVE STE 195
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-6324
Practice Address - Country:US
Practice Address - Phone:918-280-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1848760106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician