Provider Demographics
NPI:1710538673
Name:BOUTSIANIS, SAMANTHA CORINNE (CRSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:CORINNE
Last Name:BOUTSIANIS
Suffix:
Gender:F
Credentials:CRSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 JEWETT ST APT 2B
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-2879
Mailing Address - Country:US
Mailing Address - Phone:603-603-8280
Mailing Address - Fax:
Practice Address - Street 1:206 JEWETT ST APT 2B
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-2879
Practice Address - Country:US
Practice Address - Phone:603-603-8280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0217101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH0217Medicaid