Provider Demographics
NPI:1023568193
Name:SHEPPARD-SAMUEL, ROXANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ROXANN
Middle Name:
Last Name:SHEPPARD-SAMUEL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12303 193RD ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11413-1112
Mailing Address - Country:US
Mailing Address - Phone:917-862-2382
Mailing Address - Fax:
Practice Address - Street 1:12303 193RD ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11413-1112
Practice Address - Country:US
Practice Address - Phone:917-862-2382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY081061-11041C0700X
NY10238281041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool