Healthcare Provider Details

I. General information

NPI: 1295587749
Provider Name (Legal Business Name): SAMANTHA ANN MERSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2024
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 EISENHOWER DR
PARAMUS NJ
07652-1404
US

IV. Provider business mailing address

40 MAPLEWOOD AVE
BOGOTA NJ
07603-1710
US

V. Phone/Fax

Practice location:
  • Phone: 201-291-0055
  • Fax: 201-291-0888
Mailing address:
  • Phone: 201-916-3980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC00668100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number23-021
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: