Provider Demographics
NPI:1689211641
Name:FANELLI, SAMANTHA (PT, DPT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:FANELLI
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 NEW MILFORD AVE
Mailing Address - Street 2:
Mailing Address - City:DUMONT
Mailing Address - State:NJ
Mailing Address - Zip Code:07628-2820
Mailing Address - Country:US
Mailing Address - Phone:201-470-7940
Mailing Address - Fax:
Practice Address - Street 1:785 MAMARONECK AVE BLDG 8
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-2523
Practice Address - Country:US
Practice Address - Phone:914-597-2122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044706-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist