Provider Demographics
NPI:1972239093
Name:SAMUELS, SASHA SHEYENNE
Entity Type:Individual
Prefix:
First Name:SASHA
Middle Name:SHEYENNE
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 1:5540 W HARMON AVE APT 2012
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-5127
Mailing Address - Country:US
Mailing Address - Phone:818-935-4559
Mailing Address - Fax:
Practice Address - Street 1:200 HOOVER AVE UNIT 1413
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-6880
Practice Address - Country:US
Practice Address - Phone:702-350-1875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NVRBT-21-179840106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician