Provider Demographics
NPI:1720815624
Name:WANSOR, SAMANTHA LEE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEE
Last Name:WANSOR
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 1:225 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-2124
Mailing Address - Country:US
Mailing Address - Phone:724-464-8395
Mailing Address - Fax:
Practice Address - Street 1:655 CHURCH ST STE E330
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-2788
Practice Address - Country:US
Practice Address - Phone:724-465-0369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH007238103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst