Provider Demographics
NPI:1912599622
Name:NORRIS, SAMANTHA JENNINGS (RBT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JENNINGS
Last Name:NORRIS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:PAGE
Other - Last Name:JENNINGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 W SWANSON AVE
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6844
Mailing Address - Country:US
Mailing Address - Phone:907-521-0890
Mailing Address - Fax:907-357-0891
Practice Address - Street 1:300 W SWANSON AVE
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6844
Practice Address - Country:US
Practice Address - Phone:907-521-0890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI20-135944106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician