MEDICARE: SAMANTHA DIEDRE ADRASSE RBT-21-168594

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-21-168594	FL
2	222Q00000X	Developmental Therapist		FL
3	2355S0801X	Speech-Language Assistant	SI5594	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043968266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA DIEDRE ADRASSE RBT-21-168594

Provider Business Mailing Address
First Line	:	27844 MANOR OAK DR
Second Line	:
City	:	WESLEY CHAPEL
State	:	FL
Zip	:	33544-5367
Country	:	US
Telephone Number	:	754-422-4791
Fax Number	:

Provider Business Practice Location Address
First Line	:	27844 MANOR OAK DR
Second Line	:
City	:	WESLEY CHAPEL
State	:	FL
Zip	:	33544-5367
Country	:	US
Telephone Number	:	754-422-4791
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2022
Last Update Date	:	07/25/2023

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