Provider Demographics
NPI:1043887359
Name:SAMPLE, DANIELLE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:793 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-3023
Mailing Address - Country:US
Mailing Address - Phone:781-205-9304
Mailing Address - Fax:
Practice Address - Street 1:793 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-3023
Practice Address - Country:US
Practice Address - Phone:781-205-9304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-06
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist