MEDICARE: SAMARA KISTER

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	103K00000X	Behavior Analyst	1-25-86111	AZ

General Provider Information

NPI Number	:	1538096714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMARA KISTER

Provider Business Mailing Address
First Line	:	2345 E COVINA ST
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85213-7623
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2345 E COVINA ST
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85213-7623
Country	:	US
Telephone Number	:	480-529-1441
Fax Number	:

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

Provider Enumeration Date	:	05/04/2026
Last Update Date	:	05/04/2026

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Directions to “ SAMARA KISTER ” Practice Location

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