Provider Demographics
NPI:1164141594
Name:FONSECA-MOREIRA, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:FONSECA-MOREIRA
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 1:44 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:EAST WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02032-1123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:EAST WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02032-1123
Practice Address - Country:US
Practice Address - Phone:617-970-6753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOT02095225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist