Healthcare Provider Details

I. General information

NPI: 1073447801
Provider Name (Legal Business Name): MS. SAMANTHA TIRADO MARIE SAMANTHA TIRADO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 AVENUE M STE 201
BROOKLYN NY
11230-5204
US

IV. Provider business mailing address

1222 AVENUE M STE 201
BROOKLYN NY
11230-5204
US

V. Phone/Fax

Practice location:
  • Phone: 929-475-1662
  • Fax: 718-686-4373
Mailing address:
  • Phone: 929-475-1662
  • Fax: 718-686-4373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: