Provider Demographics
NPI:1972865418
Name:SMITH, SAMANTHA
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:
Last Name:SMITH
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 1:515 E 72ND ST
Mailing Address - Street 2:17F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4032
Mailing Address - Country:US
Mailing Address - Phone:914-882-3894
Mailing Address - Fax:
Practice Address - Street 1:515 E 72ND ST
Practice Address - Street 2:17F
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4032
Practice Address - Country:US
Practice Address - Phone:914-882-3894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist