Provider Demographics
NPI:1588047450
Name:MAMTSIS, SAMILA
Entity type:Individual
Prefix:MS
First Name:SAMILA
Middle Name:
Last Name:MAMTSIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SAMILA
Other - Middle Name:
Other - Last Name:MAMTSIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SEIT
Mailing Address - Street 1:1651 CONEY ISLAND AVE
Mailing Address - Street 2:2 ND FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-5849
Mailing Address - Country:US
Mailing Address - Phone:646-663-9557
Mailing Address - Fax:
Practice Address - Street 1:1651 CONEY ISLAND AVENUE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230
Practice Address - Country:US
Practice Address - Phone:646-663-9557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY824842141252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency