Healthcare Provider Details

I. General information

NPI: 1841011020
Provider Name (Legal Business Name): SAMANTHA DEAN VITTORIO BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

484 WILLIAMSON RD # 102
MOORESVILLE NC
28117-8191
US

IV. Provider business mailing address

2369 BEAM RD
COLUMBUS IN
47203-3404
US

V. Phone/Fax

Practice location:
  • Phone: 475-289-5336
  • Fax:
Mailing address:
  • Phone: 812-900-5463
  • Fax: 855-919-4295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-76682
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: