Provider Demographics
NPI:1528613197
Name:GANDULLA, SAMANTHA Y I
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:Y
Last Name:GANDULLA
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 1:218 HOLDEN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2573
Mailing Address - Country:US
Mailing Address - Phone:774-232-6052
Mailing Address - Fax:
Practice Address - Street 1:8 FANEUIL HALL MARKET PL
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-6114
Practice Address - Country:US
Practice Address - Phone:888-329-4535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician