Provider Demographics
NPI:1134559966
Name:KLEBANOW, SAMANTHA (BCBA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KLEBANOW
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16782 VON KARMAN AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-2417
Mailing Address - Country:US
Mailing Address - Phone:949-833-2237
Mailing Address - Fax:480-898-7419
Practice Address - Street 1:16782 VON KARMAN AVE STE 11
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606
Practice Address - Country:US
Practice Address - Phone:949-833-2237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-14
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1-13-14654103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst