Healthcare Provider Details

I. General information

NPI: 1497455851
Provider Name (Legal Business Name): SAMANTHA ELLIS RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11808 N OHIO ST
DUNNELLON FL
34431-6724
US

IV. Provider business mailing address

5220 SW 161ST PLACE RD
OCALA FL
34473-3014
US

V. Phone/Fax

Practice location:
  • Phone: 352-462-7021
  • Fax: 844-921-1442
Mailing address:
  • Phone: 859-585-1896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-261888
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: