Provider Demographics
NPI:1992385678
Name:SAME
Entity Type:Organization
Organization Name:SAME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST & SOCIAL WORKER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLAS
Authorized Official - Middle Name:NGUH
Authorized Official - Last Name:SANTO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, MSC
Authorized Official - Phone:442-347-7045
Mailing Address - Street 1:65 WOODS EDGE RD UNIT 6
Mailing Address - Street 2:
Mailing Address - City:FORT ASHBY
Mailing Address - State:WV
Mailing Address - Zip Code:26719-9292
Mailing Address - Country:US
Mailing Address - Phone:442-347-7045
Mailing Address - Fax:
Practice Address - Street 1:65 WOODS EDGE RD UNIT 6
Practice Address - Street 2:
Practice Address - City:FORT ASHBY
Practice Address - State:WV
Practice Address - Zip Code:26719-9292
Practice Address - Country:US
Practice Address - Phone:442-347-7045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NONE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVRG092015619Medicaid