MEDICARE: SAMANTHA THEVERAPPERUMA BCABA

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	106E00000X	Assistant Behavior Analyst

General Provider Information

NPI Number	:	1295390714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA THEVERAPPERUMA BCABA

Provider Business Mailing Address
First Line	:	5621 TIDEWATER DR
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23509-1497
Country	:	US
Telephone Number	:	757-351-4244
Fax Number	:

Provider Business Practice Location Address
First Line	:	5621 TIDEWATER DR
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23509-1497
Country	:	US
Telephone Number	:	757-351-4244
Fax Number	:

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

Provider Enumeration Date	:	05/09/2019
Last Update Date	:	01/19/2024

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