Provider Demographics
NPI:1871317776
Name:PRIETO, SAMANTHA DIANE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:DIANE
Last Name:PRIETO
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 1:14621 KIRSTEN CT
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33325-3046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6950 CYPRESS RD STE 103
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2361
Practice Address - Country:US
Practice Address - Phone:954-399-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-371945103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst