MEDICARE: SAMANTA ANNE TAKAZATO M.ED, BCBA, LBA

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	L-648	LA

General Provider Information

NPI Number	:	1578080933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTA ANNE TAKAZATO M.ED, BCBA, LBA

Provider Business Mailing Address
First Line	:	222 EARHART AVE
Second Line	:
City	:	BARKSDALE AFB
State	:	LA
Zip	:	71110-2226
Country	:	US
Telephone Number	:	240-222-2699
Fax Number	:

Provider Business Practice Location Address
First Line	:	6214 24TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-3319
Country	:	US
Telephone Number	:	212-481-4040
Fax Number	:

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

Provider Enumeration Date	:	08/27/2017
Last Update Date	:	09/13/2024

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