=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942882246
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH SHORE COLLABORATIVE PSYCHIATRY NP PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2021
-----------------------------------------------------
Last Update Date | 07/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 167 BROADWAY
-----------------------------------------------------
City | AMITYVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11701-2782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-317-9480
-----------------------------------------------------
Fax | 231-216-7467
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 167 BROADWAY
-----------------------------------------------------
City | AMITYVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11701-2782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-317-9480
-----------------------------------------------------
Fax | 231-216-7467
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PMHNP-BC
-----------------------------------------------------
Name | SAMANTHA ROCHE
-----------------------------------------------------
Credential | DNP
-----------------------------------------------------
Telephone | 631-317-9480
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------