Provider Demographics
NPI:1932494754
Name:BRODERICK, SAMANTHA LEE (BCBA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEE
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:BRODERICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:12276 SAN JOSE BLVD STE 214
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-8633
Mailing Address - Country:US
Mailing Address - Phone:706-780-1704
Mailing Address - Fax:706-780-1705
Practice Address - Street 1:1110 13TH ST STE D
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2246
Practice Address - Country:US
Practice Address - Phone:706-780-1704
Practice Address - Fax:706-780-1705
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2025-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-16-23336103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0-14-6372OtherBCABA