MEDICARE: SAMANTHA FERNANDES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-21-48633	MD

General Provider Information

NPI Number	:	1588120521
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA FERNANDES

Provider Business Mailing Address
First Line	:	2602 LORRING DR
Second Line	:
City	:	DISTRICT HEIGHTS
State	:	MD
Zip	:	20747-3310
Country	:	US
Telephone Number	:	636-295-9347
Fax Number	:

Provider Business Practice Location Address
First Line	:	2602 LORRING DR
Second Line	:
City	:	DISTRICT HEIGHTS
State	:	MD
Zip	:	20747-3310
Country	:	US
Telephone Number	:	636-295-9347
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2019
Last Update Date	:	05/19/2021

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