Provider Demographics
NPI:1801331723
Name:MORRIS, SAMUEL LANE (BCABA)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:LANE
Last Name:MORRIS
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 MIDDLE ST
Mailing Address - Street 2:UNIT 1201
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3625
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:866-610-0580
Practice Address - Street 1:1015 NW 56TH TER
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4481
Practice Address - Country:US
Practice Address - Phone:352-835-5520
Practice Address - Fax:866-610-0580
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-02
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-16-7498106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009093700Medicaid