=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144720269
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA DISADOR LCAT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2018
-----------------------------------------------------
Last Update Date | 06/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 248 HIGBIE LN FL 1
-----------------------------------------------------
City | WEST ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11795-2828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-867-2501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6619 BURNS ST
-----------------------------------------------------
City | REGO PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11374-3927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-616-0794
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101200000X
-----------------------------------------------------
Taxonomy Name | Drama Therapist
-----------------------------------------------------
License Number | 002372-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------