Healthcare Provider Details

I. General information

NPI: 1972999514
Provider Name (Legal Business Name): SAMANTHA VACCARO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2015
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 KREUTZER RD
PERU MA
01235-9265
US

IV. Provider business mailing address

21 KREUTZER RD
PERU MA
01235-9265
US

V. Phone/Fax

Practice location:
  • Phone: 413-358-1099
  • Fax:
Mailing address:
  • Phone: 413-358-1099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number127294
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: