Provider Demographics
NPI:1164975264
Name:TARDIF, SAMANTHA (BCBA, LABA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:TARDIF
Suffix:
Gender:F
Credentials:BCBA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 COLE ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-1953
Mailing Address - Country:US
Mailing Address - Phone:207-689-7621
Mailing Address - Fax:
Practice Address - Street 1:9 COLE ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-1953
Practice Address - Country:US
Practice Address - Phone:207-689-7621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11519047103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst