Provider Demographics
NPI:1053102657
Name:KINNEY, SAMANTHA RAE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RAE
Last Name:KINNEY
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 1:1221 TULIP ST APT 328
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-4527
Mailing Address - Country:US
Mailing Address - Phone:315-484-4653
Mailing Address - Fax:
Practice Address - Street 1:7767 OSWEGO RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-2322
Practice Address - Country:US
Practice Address - Phone:315-992-1929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-14
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYBACB1240771106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician