Provider Demographics
NPI:1780268847
Name:MANDUCA, SAMANTHA ROSE (MSED, LPA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ROSE
Last Name:MANDUCA
Suffix:
Gender:F
Credentials:MSED, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110A EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:ROCKWELL
Mailing Address - State:NC
Mailing Address - Zip Code:28138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110A EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:ROCKWELL
Practice Address - State:NC
Practice Address - Zip Code:28138
Practice Address - Country:US
Practice Address - Phone:704-279-0626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5878103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist