Provider Demographics
NPI:1104403278
Name:SAMSON, ALEX
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:SAMSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1081 KOKOMO RD
Mailing Address - Street 2:
Mailing Address - City:HAIKU
Mailing Address - State:HI
Mailing Address - Zip Code:96708-5006
Mailing Address - Country:US
Mailing Address - Phone:631-664-8362
Mailing Address - Fax:
Practice Address - Street 1:1081 KOKOMO RD
Practice Address - Street 2:
Practice Address - City:HAIKU
Practice Address - State:HI
Practice Address - Zip Code:96708-5006
Practice Address - Country:US
Practice Address - Phone:631-664-8362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
CA1-21-48412103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst