Provider Demographics
NPI:1841830155
Name:BLAKE, SAMANTHA R (BCBA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:R
Last Name:BLAKE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44235 GALICIA DR
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-9125
Mailing Address - Country:US
Mailing Address - Phone:909-228-0298
Mailing Address - Fax:
Practice Address - Street 1:44235 GALICIA DR
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544-9125
Practice Address - Country:US
Practice Address - Phone:909-228-0298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-17-28663103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst