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General NPI Number Information
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NPI Number | 1477121978
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Entity Type | Individual
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Provider Name | SAMANTHA LYNN DORUM MS, BCBA
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Gender | Female
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Dates
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Enumeration Date | 06/12/2021
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Last Update Date | 06/12/2021
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Provider Practice Location Address
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Address Line | 1025 ATLANTIC AVE STE 101
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City | ALAMEDA
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State | CA
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Zip | 94501-1188
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Country | US
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Telephone | 510-268-8120
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Fax |
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Provider Business Mailing Address
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Address Line | 4601 79TH AVENUE CT W
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City | UNIVERSITY PLACE
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State | WA
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Zip | 98466-3037
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Country | US
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Telephone | 253-298-7295
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | BACB500114
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License Number State | WA
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