Provider Demographics
NPI:1235835117
Name:DOWSTRA, SAMANTHA (LAC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:DOWSTRA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2036
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-8036
Mailing Address - Country:US
Mailing Address - Phone:732-785-3000
Mailing Address - Fax:
Practice Address - Street 1:105 HENDRICKSON AVE
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-2574
Practice Address - Country:US
Practice Address - Phone:732-785-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00683200101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0029807Medicaid