Provider Demographics
NPI:1720703804
Name:SAMSON-PEAN, AYSHA DOROTEA
Entity Type:Individual
Prefix:
First Name:AYSHA
Middle Name:DOROTEA
Last Name:SAMSON-PEAN
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 1:2001 W DEKLE AVE APT G
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3244
Mailing Address - Country:US
Mailing Address - Phone:619-459-9663
Mailing Address - Fax:
Practice Address - Street 1:5100 78TH AVE N STE 6
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-2407
Practice Address - Country:US
Practice Address - Phone:727-289-9626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-204237106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty