Provider Demographics
NPI:1184305765
Name:MCELROY, SAMANTHA LEIGH
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEIGH
Last Name:MCELROY
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 1:120 PALENCIA VILLAGE DR. #C-105
Mailing Address - Street 2:STE. 164
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095
Mailing Address - Country:US
Mailing Address - Phone:904-201-9129
Mailing Address - Fax:
Practice Address - Street 1:175 CUMBERLAND PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-8955
Practice Address - Country:US
Practice Address - Phone:904-201-9129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-284146106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician