Provider Demographics
NPI:1194220830
Name:SAMUEL POWELL, JANICE (SDL)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:SAMUEL POWELL
Suffix:
Gender:F
Credentials:SDL
Other - Prefix:
Other - First Name:JANICE
Other - Middle Name:
Other - Last Name:SAMUEL DAE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SDL
Mailing Address - Street 1:285 FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-3813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 MANHATTAN AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10607-1329
Practice Address - Country:US
Practice Address - Phone:914-761-6134
Practice Address - Fax:914-761-5461
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst