1508986928 NPI number — SAMANTHA MARIA GORRELL

Table of content: SAMANTHA MARIA GORRELL (NPI 1508986928)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508986928 NPI number — SAMANTHA MARIA GORRELL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORRELL
Provider First Name:
SAMANTHA
Provider Middle Name:
MARIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MATTOCCIA
Provider Other First Name:
SAMANTHA
Provider Other Middle Name:
MARIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508986928
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1311 MAMARONECK AVE STE 140
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE PLAINS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10605-5224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-777-8705
Provider Business Mailing Address Fax Number:
631-760-8306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1915 GUERNSEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ABINGTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19001-3701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-659-8600
Provider Business Practice Location Address Fax Number:
215-659-4498
Provider Enumeration Date:
03/30/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  40QA01899700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT016903 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)