Provider Demographics
NPI:1699476705
Name:DAS, SAMPA I
Entity type:Individual
Prefix:
First Name:SAMPA
Middle Name:
Last Name:DAS
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 1:64- 05 WOODSIDE AVE AP 2 B
Mailing Address - Street 2:64-05 WOODSIDE AVE AP 2B
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377
Mailing Address - Country:US
Mailing Address - Phone:929-462-9072
Mailing Address - Fax:
Practice Address - Street 1:6405 AP 2B WOODSIDE AVE
Practice Address - Street 2:4806 59 PL
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377
Practice Address - Country:US
Practice Address - Phone:929-462-9072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty