Healthcare Provider Details

I. General information

NPI: 1629532106
Provider Name (Legal Business Name): SAMANTHA HAGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA MATHERLY

II. Dates (important events)

Enumeration Date: 01/29/2019
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 N DIXIE AVE STE 114
ELIZABETHTOWN KY
42701-7494
US

IV. Provider business mailing address

1321 MURFREESBORO PIKE STE 702
NASHVILLE TN
37217-2679
US

V. Phone/Fax

Practice location:
  • Phone: 270-702-4641
  • Fax: 615-577-5654
Mailing address:
  • Phone: 615-724-4722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: