Provider Demographics
NPI:1215419833
Name:DOVE, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:DOVE
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 1:2804 E. 26TH STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-4019
Mailing Address - Country:US
Mailing Address - Phone:605-271-2690
Mailing Address - Fax:605-271-3956
Practice Address - Street 1:1704 WESTLAND RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3322
Practice Address - Country:US
Practice Address - Phone:307-222-2400
Practice Address - Fax:605-271-3956
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-18-64091106E00000X
106S00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-20-44460OtherBOARD CERTIFICATE