1992294870 NPI number — SAMANTHA CAROLINE ANN NACE CBT

Table of content: SAMANTHA CAROLINE ANN NACE CBT (NPI 1992294870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992294870 NPI number — SAMANTHA CAROLINE ANN NACE CBT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NACE
Provider First Name:
SAMANTHA
Provider Middle Name:
CAROLINE ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CBT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992294870
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 425
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAIR
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98528-0425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-813-2835
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2313 SW 339TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FEDERAL WAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98023-7730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-981-3897
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/06/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106S00000X , with the licence number:  60829714 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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