Provider Demographics
NPI:1821539115
Name:VOLLERTSEN, SAMANTHA JEAN
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:JEAN
Last Name:VOLLERTSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SAMANTHA
Other - Middle Name:JEAN
Other - Last Name:HACKMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2331 HANSEN COURT
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301
Mailing Address - Country:US
Mailing Address - Phone:850-320-6555
Mailing Address - Fax:888-873-4610
Practice Address - Street 1:2331 HANSEN COURT
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301
Practice Address - Country:US
Practice Address - Phone:850-320-6555
Practice Address - Fax:888-873-4610
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FL17-35394106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17-35394OtherRBT
FL024665300Medicaid