Provider Demographics
NPI:1235803560
Name:ROTAY, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:ROTAY
Suffix:
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 1:171 SOUTH ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3919
Mailing Address - Country:US
Mailing Address - Phone:717-682-6735
Mailing Address - Fax:
Practice Address - Street 1:632 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02121-3293
Practice Address - Country:US
Practice Address - Phone:617-729-2465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2024-06-11
Deactivation Date:2022-07-01
Deactivation Code:
Reactivation Date:2024-06-11
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist