Provider Demographics
NPI:1588120521
Name:FERNANDES, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:FERNANDES
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 1:2602 LORRING DR
Mailing Address - Street 2:
Mailing Address - City:DISTRICT HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20747-3310
Mailing Address - Country:US
Mailing Address - Phone:636-295-9347
Mailing Address - Fax:
Practice Address - Street 1:2602 LORRING DR
Practice Address - Street 2:
Practice Address - City:DISTRICT HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20747-3310
Practice Address - Country:US
Practice Address - Phone:636-295-9347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1-21-48633103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst