Provider Demographics
NPI:1306428594
Name:WONDSEL, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WONDSEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 HEWLETT AVE
Mailing Address - Street 2:
Mailing Address - City:POINT LOOKOUT
Mailing Address - State:NY
Mailing Address - Zip Code:11569
Mailing Address - Country:US
Mailing Address - Phone:516-780-2812
Mailing Address - Fax:
Practice Address - Street 1:1000 N VILLAGE AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-1000
Practice Address - Country:US
Practice Address - Phone:516-705-1636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021362225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist