MEDICARE: SASHA SHEYENNE SAMUELS

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	106S00000X	Behavior Technician
2	106S00000X	Behavior Technician	RBT-21-179840	NV

General Provider Information

NPI Number	:	1972239093
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SASHA SHEYENNE SAMUELS

Provider Business Mailing Address
First Line	:	5540 W HARMON AVE APT 2012
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-5127
Country	:	US
Telephone Number	:	818-935-4559
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 HOOVER AVE UNIT 1413
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89101-6880
Country	:	US
Telephone Number	:	702-350-1875
Fax Number	:

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

Provider Enumeration Date	:	07/29/2022
Last Update Date	:	07/29/2022

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