Provider Demographics
NPI:1518610203
Name:FASOLINO, SAMANTHA MARIA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIA
Last Name:FASOLINO
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 1:2260 DUCK POND RD
Mailing Address - Street 2:
Mailing Address - City:CUTCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11935-1806
Mailing Address - Country:US
Mailing Address - Phone:631-655-1291
Mailing Address - Fax:
Practice Address - Street 1:28 N COUNTRY RD
Practice Address - Street 2:
Practice Address - City:MOUNT SINAI
Practice Address - State:NY
Practice Address - Zip Code:11766-1518
Practice Address - Country:US
Practice Address - Phone:888-975-2256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health