Provider Demographics
NPI:1962082974
Name:GROOM-SHEDDLER, SAMANTHA TARA MAGDALENA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:TARA MAGDALENA
Last Name:GROOM-SHEDDLER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:813-220-7910
Mailing Address - Fax:772-675-9100
Practice Address - Street 1:7108 S KANNER HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-7462
Practice Address - Country:US
Practice Address - Phone:813-220-7910
Practice Address - Fax:772-675-9100
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-21-160240106S00000X
FL1-25-79388103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician