Provider Demographics
NPI:1457162083
Name:FONTANA, SAMANTHA JEAN I
Entity type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:JEAN
Last Name:FONTANA
Suffix:I
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 1:11 PARKVIEW PL
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-3441
Mailing Address - Country:US
Mailing Address - Phone:516-303-3631
Mailing Address - Fax:
Practice Address - Street 1:3249 KINGSBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-5514
Practice Address - Country:US
Practice Address - Phone:646-204-2295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health