Provider Demographics
NPI:1154839298
Name:MEDLYN, SAMANTHA (BCBA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MEDLYN
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:PO BOX 767938
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-7938
Mailing Address - Country:US
Mailing Address - Phone:818-241-6780
Mailing Address - Fax:818-241-6853
Practice Address - Street 1:201 JACKSON ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-5524
Practice Address - Country:US
Practice Address - Phone:818-241-6780
Practice Address - Fax:818-241-6853
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-17-39088106S00000X
CO1-20-44967103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician