Healthcare Provider Details

I. General information

NPI: 1871133801
Provider Name (Legal Business Name): MISS SAMANTHA JEAN LACASSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2020
Last Update Date: 07/11/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 GATEWAY BLVD
SOUTH SAN FRANCISCO CA
94080-7017
US

IV. Provider business mailing address

140 W WOOD ST UNIT 104
PALATINE IL
60067-5041
US

V. Phone/Fax

Practice location:
  • Phone: 760-668-8879
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-82537
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: