=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205134038
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA GAYL BRODLIEB MA.ED., BCBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2011
-----------------------------------------------------
Last Update Date | 03/02/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 E 8TH ST APT 14L
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003-6514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-319-5907
-----------------------------------------------------
Fax | 917-675-7451
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 60 E 8TH ST APT 14L
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10003-6514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-319-5907
-----------------------------------------------------
Fax | 917-675-7451
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1107622
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------