Healthcare Provider Details

I. General information

NPI: 1962992495
Provider Name (Legal Business Name): SAMANTHA DUTRA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 05/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69 APPLETON ST
ARLINGTON MA
02476-5955
US

IV. Provider business mailing address

69 APPLETON ST
ARLINGTON MA
02476-5955
US

V. Phone/Fax

Practice location:
  • Phone: 781-218-9773
  • Fax:
Mailing address:
  • Phone: 781-218-9773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. SAMANTHA DUTRA
Title or Position: OWNER
Credential:
Phone: 781-918-9773