Provider Demographics
NPI:1205134038
Name:BRODLIEB, SAMANTHA GAYL (MAED, BCBA)
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:GAYL
Last Name:BRODLIEB
Suffix:
Gender:F
Credentials:MAED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 E 8TH ST
Mailing Address - Street 2:APT 14L
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-6514
Mailing Address - Country:US
Mailing Address - Phone:516-319-5907
Mailing Address - Fax:917-675-7451
Practice Address - Street 1:60 E 8TH ST
Practice Address - Street 2:APT 14L
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-6514
Practice Address - Country:US
Practice Address - Phone:516-319-5907
Practice Address - Fax:917-675-7451
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1107622103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst