Provider Demographics
NPI:1356990667
Name:MOORE, SAMANTHA D (MA, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:D
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 SHEIDLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BONNER SPRINGS
Mailing Address - State:KS
Mailing Address - Zip Code:66012-9514
Mailing Address - Country:US
Mailing Address - Phone:816-301-4533
Mailing Address - Fax:
Practice Address - Street 1:913 SHEIDLEY AVE
Practice Address - Street 2:
Practice Address - City:BONNER SPRINGS
Practice Address - State:KS
Practice Address - Zip Code:66012-9514
Practice Address - Country:US
Practice Address - Phone:816-301-4533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLBA00464103K00000X
MO2023005307103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst