Provider Demographics
NPI:1447775135
Name:ACANFORA, SAMANTHA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:
Last Name:ACANFORA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:MARIE
Other - Last Name:TORELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 7720
Mailing Address - Street 2:CREDENTIALING SPECIALIST
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-0720
Mailing Address - Country:US
Mailing Address - Phone:203-503-3174
Mailing Address - Fax:203-503-3183
Practice Address - Street 1:226 DIXWELL AVENUE
Practice Address - Street 2:NORTHSIDE COMMUNITY OUTPATIENT SERVICES
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3456
Practice Address - Country:US
Practice Address - Phone:203-503-3470
Practice Address - Fax:203-503-3478
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT107041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008089584Medicaid