Provider Demographics
NPI:1326543117
Name:MOELLER, SAMANTHA (BCBA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MOELLER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2354 POWELL ST STE A
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 HARRIS INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8853
Practice Address - Country:US
Practice Address - Phone:912-331-0846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst