Provider Demographics
NPI:1033353750
Name:BOUTIS, SAMANTHA LYN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:LYN
Last Name:BOUTIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:LYN
Other - Last Name:HERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:430 SILLS RD
Mailing Address - Street 2:
Mailing Address - City:YAPHANK
Mailing Address - State:NY
Mailing Address - Zip Code:11980
Mailing Address - Country:US
Mailing Address - Phone:631-924-5583
Mailing Address - Fax:
Practice Address - Street 1:430 SILLS RD
Practice Address - Street 2:
Practice Address - City:YAPHANK
Practice Address - State:NY
Practice Address - Zip Code:11980
Practice Address - Country:US
Practice Address - Phone:631-924-5583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-24
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297457103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool