=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366937567
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA MARIE LAROSA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2018
-----------------------------------------------------
Last Update Date | 06/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 652 WILLOUGHBY AVENUE
-----------------------------------------------------
City | BUSHWICK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-244-1426
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 116 PROSPECT ST
-----------------------------------------------------
City | PORT JEFFERSON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11777-1813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-278-0887
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 103455
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------