Provider Demographics
NPI:1063125748
Name:VALLE, SAMANTA
Entity type:Individual
Prefix:
First Name:SAMANTA
Middle Name:
Last Name:VALLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5730 W WOODBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-9498
Mailing Address - Country:US
Mailing Address - Phone:209-490-9562
Mailing Address - Fax:
Practice Address - Street 1:5730 W WOODBRIDGE RD
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-9498
Practice Address - Country:US
Practice Address - Phone:209-490-9562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-28
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst