Provider Demographics
NPI:1528653193
Name:SAM, SAMANTHA OUK (BCBA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:OUK
Last Name:SAM
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 1:6421 CAMP BOWIE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-5419
Mailing Address - Country:US
Mailing Address - Phone:817-353-2090
Mailing Address - Fax:
Practice Address - Street 1:6421 CAMP BOWIE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5419
Practice Address - Country:US
Practice Address - Phone:817-353-2090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-05
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-24-77765103K00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician