Healthcare Provider Details

I. General information

NPI: 1932874419
Provider Name (Legal Business Name): SAMANTHA ELLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2021
Last Update Date: 02/07/2026
Certification Date: 02/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11-13 SUNFLOWER AVE STE 1020
PARAMUS NJ
07652-3756
US

IV. Provider business mailing address

PO BOX 748465
ATLANTA GA
30374-8465
US

V. Phone/Fax

Practice location:
  • Phone: 973-529-8913
  • Fax:
Mailing address:
  • Phone: 855-284-7483
  • Fax: 617-807-0958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC01028000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: