MEDICARE: MRS. SAMANTHA JOANNE SANTOS MA, LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	37AC00322900	NJ

General Provider Information

NPI Number	:	1639691801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SAMANTHA JOANNE SANTOS MA, LAC

Provider Business Mailing Address
First Line	:	12 N WOODSIDE AVE
Second Line	:	2ND FLOOR
City	:	LODI
State	:	NJ
Zip	:	07644
Country	:	US
Telephone Number	:	201-981-2694
Fax Number	:	201-981-2694

Provider Business Practice Location Address
First Line	:	650 BLOOMFIELD AVE
Second Line	:
City	:	BLOOMFIELD
State	:	NJ
Zip	:	07003-2512
Country	:	US
Telephone Number	:	201-981-2694
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2017
Last Update Date	:	07/10/2017

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