Provider Demographics
NPI:1972095305
Name:SAMUELS, CHANAKAY 4079157720
Entity Type:Individual
Prefix:
First Name:CHANAKAY
Middle Name:4079157720
Last Name:SAMUELS
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 1:244 ALTAMONTE BAY CLUB CIR APT 202
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5830
Mailing Address - Country:US
Mailing Address - Phone:617-756-9865
Mailing Address - Fax:
Practice Address - Street 1:791 RINEHART RD FL 32746
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-4876
Practice Address - Country:US
Practice Address - Phone:617-756-9865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst