Provider Demographics
NPI:1972193399
Name:KELLEY-STEVENS, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KELLEY-STEVENS
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 1:14852 GALAPAGO ST APT K306
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80023-8872
Mailing Address - Country:US
Mailing Address - Phone:781-789-9303
Mailing Address - Fax:
Practice Address - Street 1:12303 E 104TH PL UNIT 105
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80022-2098
Practice Address - Country:US
Practice Address - Phone:720-617-1574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty