Provider Demographics
NPI:1235724576
Name:SAMPSON, IMANIE CHANTEL
Entity Type:Individual
Prefix:
First Name:IMANIE
Middle Name:CHANTEL
Last Name:SAMPSON
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 1:91 AMES ST APT C178
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-3027
Mailing Address - Country:US
Mailing Address - Phone:617-586-9070
Mailing Address - Fax:
Practice Address - Street 1:91 AMES ST APT C178
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-3027
Practice Address - Country:US
Practice Address - Phone:617-586-9070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician