Provider Demographics
NPI:1467893115
Name:BERG, SAMANTHA ASHLEY
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:ASHLEY
Last Name:BERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:ASHLEY
Other - Last Name:SPILLANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:635 165 STREET
Mailing Address - Street 2:PROMISE PROGRAM 6TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032
Mailing Address - Country:US
Mailing Address - Phone:212-305-4360
Mailing Address - Fax:
Practice Address - Street 1:635 165 STREET
Practice Address - Street 2:PROMISE PROGRAM 6TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:212-305-4360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health