Basic Information
Provider Information | |||||||||
NPI: | 1821539115 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VOLLERTSEN | ||||||||
FirstName: | SAMANTHA | ||||||||
MiddleName: | JEAN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HACKMANN | ||||||||
OtherFirstName: | SAMANTHA | ||||||||
OtherMiddleName: | JEAN | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2331 HANSEN COURT | ||||||||
Address2: |   | ||||||||
City: | TALLAHASSEE | ||||||||
State: | FL | ||||||||
PostalCode: | 32301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8503206555 | ||||||||
FaxNumber: | 8888734610 | ||||||||
Practice Location | |||||||||
Address1: | 2331 HANSEN COURT | ||||||||
Address2: |   | ||||||||
City: | TALLAHASSEE | ||||||||
State: | FL | ||||||||
PostalCode: | 32301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8503206555 | ||||||||
FaxNumber: | 8888734610 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/20/2017 | ||||||||
LastUpdateDate: | 02/12/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X |   |   | N |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   | 106S00000X | 17-35394 | FL | Y |   |   |   |   |
ID Information
ID | Type | State | Issuer | Description | 17-35394 | 01 | FL | RBT | OTHER | 024665300 | 05 | FL |   | MEDICAID |