Provider Demographics
NPI:1700584836
Name:DESIDERIO, SAMANTHA (LMHC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:DESIDERIO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3285B RICHMOND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-2123
Mailing Address - Country:US
Mailing Address - Phone:347-671-7038
Mailing Address - Fax:
Practice Address - Street 1:3285B RICHMOND AVE STE 200
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-2123
Practice Address - Country:US
Practice Address - Phone:347-238-8986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-17
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012317101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY012317-01OtherLICENSE