Provider Demographics
NPI:1851996193
Name:RICCI, SAMANTHA DANIELLE
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:DANIELLE
Last Name:RICCI
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 1:124 WATERTOWN ST STE 2D
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-2500
Mailing Address - Country:US
Mailing Address - Phone:617-916-5069
Mailing Address - Fax:
Practice Address - Street 1:124 WATERTOWN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-2576
Practice Address - Country:US
Practice Address - Phone:617-916-5069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 390200000X
MA000227181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program