Provider Demographics
NPI:1033945597
Name:SAMENUK, NICHOLAS JACOB
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JACOB
Last Name:SAMENUK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 S JONES BLVD APT 1047
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-6152
Mailing Address - Country:US
Mailing Address - Phone:419-344-5707
Mailing Address - Fax:
Practice Address - Street 1:6767 W TROPICANA AVE STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-4755
Practice Address - Country:US
Practice Address - Phone:702-209-0370
Practice Address - Fax:702-463-1851
Is Sole Proprietor?:No
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst