Provider Demographics
NPI:1386339695
Name:MUNOZ, SAMANTHA GRACE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:GRACE
Last Name:MUNOZ
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 1:3661 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-8218
Mailing Address - Country:US
Mailing Address - Phone:239-245-8761
Mailing Address - Fax:239-689-8694
Practice Address - Street 1:3669 SW 2ND AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2856
Practice Address - Country:US
Practice Address - Phone:352-554-6164
Practice Address - Fax:352-240-6876
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-267510106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician