Provider Demographics
NPI:1932720687
Name:LEITAO, SAMANTHA (BCBA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:LEITAO
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 1:120 COON DEN RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07422-2078
Mailing Address - Country:US
Mailing Address - Phone:973-617-6705
Mailing Address - Fax:
Practice Address - Street 1:120 COON DEN RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07422-2078
Practice Address - Country:US
Practice Address - Phone:973-617-6705
Practice Address - Fax:201-621-4346
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-20-40755103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ474541987Medicaid