Provider Demographics
NPI:1639691801
Name:SANTOS, SAMANTHA JOANNE (MA, LAC)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:JOANNE
Last Name:SANTOS
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:REBELO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12 N WOODSIDE AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:LODI
Mailing Address - State:NJ
Mailing Address - Zip Code:07644
Mailing Address - Country:US
Mailing Address - Phone:201-981-2694
Mailing Address - Fax:201-981-2694
Practice Address - Street 1:650 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-2512
Practice Address - Country:US
Practice Address - Phone:201-981-2694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00322900101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health