Provider Demographics
NPI:1649620451
Name:SARDONE, SAMANTHA GAYLE (MED BCBA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:GAYLE
Last Name:SARDONE
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 1:2663 CEDAR DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-1325
Mailing Address - Country:US
Mailing Address - Phone:856-630-0264
Mailing Address - Fax:
Practice Address - Street 1:885 WOODSTOCK RD
Practice Address - Street 2:STE 430-226
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-2277
Practice Address - Country:US
Practice Address - Phone:770-992-8534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-14-17660103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst