Provider Demographics
NPI:1730515966
Name:HARDESTY, SAMANTHA LYNN (MA, BCBA)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:LYNN
Last Name:HARDESTY
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2126 E BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-2041
Mailing Address - Country:US
Mailing Address - Phone:804-519-1360
Mailing Address - Fax:
Practice Address - Street 1:2126 E BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-2041
Practice Address - Country:US
Practice Address - Phone:804-519-1360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-08-4368103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD5463050-00Medicaid