Provider Demographics
NPI:1326688086
Name:BERGIN, SAMANTHA (BCBA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BERGIN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 ELAINE DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-4602
Mailing Address - Country:US
Mailing Address - Phone:914-316-3166
Mailing Address - Fax:
Practice Address - Street 1:4080 MCGINNIS FERRY RD STE 301
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-1737
Practice Address - Country:US
Practice Address - Phone:678-710-2324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-19-39063103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst