Provider Demographics
NPI:1093866766
Name:SAMANIEGO, SANDRA ODALIA (PHD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:ODALIA
Last Name:SAMANIEGO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 2ND AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-3313
Mailing Address - Country:US
Mailing Address - Phone:212-434-3364
Mailing Address - Fax:212-717-5691
Practice Address - Street 1:1430 2ND AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-3313
Practice Address - Country:US
Practice Address - Phone:212-434-3364
Practice Address - Fax:212-717-5691
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007420103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist