Provider Demographics
NPI:1295158657
Name:LLOYD, SAMANTHA J
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:J
Last Name:LLOYD
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 1:915 N TOWER AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-4942
Mailing Address - Country:US
Mailing Address - Phone:360-520-2806
Mailing Address - Fax:
Practice Address - Street 1:4128 MERIDIAN RD NE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-2347
Practice Address - Country:US
Practice Address - Phone:808-292-0784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60429421Medicaid