Healthcare Provider Details

I. General information

NPI: 1639717689
Provider Name (Legal Business Name): SAMANTHA ANNE HASKINS RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2019
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11820 MUNBURY DR
DADE CITY FL
33525-5747
US

IV. Provider business mailing address

PO BOX 623
SAN ANTONIO FL
33576-0623
US

V. Phone/Fax

Practice location:
  • Phone: 352-999-0447
  • Fax: 352-437-4921
Mailing address:
  • Phone: 352-999-0447
  • Fax: 352-437-4921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-66185
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: