Provider Demographics
NPI:1356721039
Name:DESISTO, SAMANTHA (LMHC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:DESISTO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:TILTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:800 CUMMINGS CENTER
Mailing Address - Street 2:SUITE 266T
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915
Mailing Address - Country:US
Mailing Address - Phone:978-998-3680
Mailing Address - Fax:978-922-0098
Practice Address - Street 1:800 CUMMINGS CENTER
Practice Address - Street 2:SUITE 266T
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915
Practice Address - Country:US
Practice Address - Phone:978-998-3680
Practice Address - Fax:978-922-0098
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MA10764101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical