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NPI Code Detail

MEDICARE: SAMANTHA RENEA BACON

MEDICARE: SAMANTHA RENEA BACON
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
1106S00000XBehavior Technician

General Provider Information

NPI Number : 1881352441
Entity Type Code : Individual
Provider Name (Legal Business Name) : SAMANTHA RENEA BACON
Provider Business Mailing Address
First Line : 139 GALYON ST
Second Line :
City : SWEETWATER
State : TN
Zip : 37874-5539
Country : US
Telephone Number : 865-227-3898
Fax Number :
Provider Business Practice Location Address
First Line : 440 STUART RD NE STE 2
Second Line :
City : CLEVELAND
State : TN
Zip : 37312-4959
Country : US
Telephone Number : 844-244-1818
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/01/2021
Last Update Date : 12/01/2021

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Directions to “ SAMANTHA RENEA BACON ” Practice Location

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