Healthcare Provider Details

I. General information

NPI: 1831135227
Provider Name (Legal Business Name): SAMANTHA L HELLER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 05/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 MAIN AVE STE 201
NORWALK CT
06851-1176
US

IV. Provider business mailing address

491 WILSON ST
FAIRFIELD CT
06825-1427
US

V. Phone/Fax

Practice location:
  • Phone: 203-838-4000
  • Fax: 203-845-9535
Mailing address:
  • Phone: 646-242-9633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number867489
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: