Provider Demographics
NPI:1043372030
Name:SAMUEL-SIEGEL, PHILLIP (LCSW)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:
Last Name:SAMUEL-SIEGEL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:PHILLIP
Other - Middle Name:
Other - Last Name:SAMUEL-SIEGEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:130 POWERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BOONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07005-8705
Mailing Address - Country:US
Mailing Address - Phone:973-316-1869
Mailing Address - Fax:973-316-1920
Practice Address - Street 1:130 POWERVILLE RD
Practice Address - Street 2:
Practice Address - City:BOONTON
Practice Address - State:NJ
Practice Address - Zip Code:07005-8705
Practice Address - Country:US
Practice Address - Phone:973-316-1869
Practice Address - Fax:973-316-1920
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC052683001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical