Provider Demographics
NPI:1134929698
Name:BORES, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BORES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 PEANUT HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36048-3530
Mailing Address - Country:US
Mailing Address - Phone:205-363-2172
Mailing Address - Fax:
Practice Address - Street 1:1556 ANDREW'S AVE
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360
Practice Address - Country:US
Practice Address - Phone:205-363-2172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-14
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician