Provider Demographics
NPI:1104519727
Name:IRVIN, SAMANTHA LYNN
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNN
Last Name:IRVIN
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 1:1220 MCGEE CT NE APT 103
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-9442
Mailing Address - Country:US
Mailing Address - Phone:971-599-8899
Mailing Address - Fax:
Practice Address - Street 1:1605 E LINCOLN RD # RC
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071-5137
Practice Address - Country:US
Practice Address - Phone:503-982-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician