Basic Information
| Provider Information | |||||||||
| NPI: | 1114437548 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.ED, BCBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARTLESS | ||||||||
| OtherFirstName: | SAMANTHA | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 22641 FRONTAGE RD | ||||||||
| Address2: | |||||||||
| City: | BRYANT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720229117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5015473053 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 22461 I-30 FRONTAGE RD | ||||||||
| Address2: | 1100B | ||||||||
| City: | BRYANT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5015743053 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2017 | ||||||||
| LastUpdateDate: | 11/15/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | C-022 | LA | N | 103K00000X | 1-18-31009 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.