=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558801431
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA ELIZABETH DIMISA PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2017
-----------------------------------------------------
Last Update Date | 02/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 PARK ROW NEW YORK
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10007-1704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-836-6335
-----------------------------------------------------
Fax | 646-836-7712
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 BARROW ST APT. 5
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10014-3740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-652-4477
-----------------------------------------------------
Fax | 646-836-7712
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TF0200X
-----------------------------------------------------
Taxonomy Name | Forensic Psychologist
-----------------------------------------------------
License Number | 020282-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------