Basic Information
| Provider Information | |||||||||
| NPI: | 1467963330 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DRAGER | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | NICCOLE | ||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10827 | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323022827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505210242 | ||||||||
| FaxNumber: | 8505211973 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 KYLE WOOD LN | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335114850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135481009 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2017 | ||||||||
| LastUpdateDate: | 03/21/2018 | ||||||||
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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 | 103K00000X | FL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 018620000 | 05 | FL | MEDICAID |