Healthcare Provider Details

I. General information

NPI: 1881101632
Provider Name (Legal Business Name): SAMANTHA ANNE SIPES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2018
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1926 VIA CTR STE B
VISTA CA
92081-6056
US

IV. Provider business mailing address

1926 VIA CTR STE B
VISTA CA
92081-6056
US

V. Phone/Fax

Practice location:
  • Phone: 760-294-1206
  • Fax:
Mailing address:
  • Phone: 760-294-1206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-40129
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-16-26831
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: