Healthcare Provider Details

I. General information

NPI: 1861252264
Provider Name (Legal Business Name): SAMANTHA ROSE KUYKENDALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2024
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

272 S COLLINS RD STE 200
SUNNYVALE TX
75182-4643
US

IV. Provider business mailing address

750 JUSTIN RD
ROCKWALL TX
75087-4822
US

V. Phone/Fax

Practice location:
  • Phone: 469-458-9021
  • Fax:
Mailing address:
  • Phone: 469-458-9021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-296757
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: