Provider Demographics
NPI:1861908139
Name:VANDERGRIFT, SAMANTHA M (BCABA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:M
Last Name:VANDERGRIFT
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 E 88TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-1235
Mailing Address - Country:US
Mailing Address - Phone:317-849-5437
Mailing Address - Fax:317-436-8911
Practice Address - Street 1:7901 E 88TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1235
Practice Address - Country:US
Practice Address - Phone:317-849-5437
Practice Address - Fax:317-436-8911
Is Sole Proprietor?:No
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0-17-7763106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst