Provider Demographics
NPI:1669188546
Name:PRYSTOWSKY, SAMARA MELLANIE
Entity type:Individual
Prefix:
First Name:SAMARA
Middle Name:MELLANIE
Last Name:PRYSTOWSKY
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 1:929 HARRISON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1300
Mailing Address - Country:US
Mailing Address - Phone:614-940-4868
Mailing Address - Fax:
Practice Address - Street 1:929 HARRISON AVE STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1300
Practice Address - Country:US
Practice Address - Phone:614-940-4868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.22986291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical