MEDICARE: SAMUEL SPACK

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-22-233179	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	:	1598488579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL SPACK

Provider Business Mailing Address
First Line	:	7108 S KANNER HWY
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34997-7462
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10121 SHEPHARD ST # 8-301
Second Line	:
City	:	ESTERO
State	:	FL
Zip	:	33967-4800
Country	:	US
Telephone Number	:	561-319-8255
Fax Number	:

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

Provider Enumeration Date	:	09/23/2022
Last Update Date	:	09/23/2022

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Directions to “ SAMUEL SPACK ” Practice Location

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