Provider Demographics
NPI:1710308176
Name:RICHARDSON, SAMANTHA (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3211 GRANT LINE RD
Mailing Address - Street 2:SUITE 15
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-2175
Mailing Address - Country:US
Mailing Address - Phone:360-951-7141
Mailing Address - Fax:866-859-3937
Practice Address - Street 1:3211 GRANT LINE RD
Practice Address - Street 2:SUITE 15
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-2175
Practice Address - Country:US
Practice Address - Phone:360-951-7141
Practice Address - Fax:866-859-3937
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
11315032103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst