Provider Demographics
NPI:1194503276
Name:MOTTOLA, SAMANTHA A (LAC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:A
Last Name:MOTTOLA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CLARK CT
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-1301
Mailing Address - Country:US
Mailing Address - Phone:201-741-9302
Mailing Address - Fax:
Practice Address - Street 1:44 UNION AVE
Practice Address - Street 2:
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070-1275
Practice Address - Country:US
Practice Address - Phone:201-741-9302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00714900101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health