Provider Demographics
NPI:1225496870
Name:DAVIS, SAMANTHA ESTELLE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ESTELLE
Last Name:DAVIS
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 1:499 GLEN ST
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-2205
Mailing Address - Country:US
Mailing Address - Phone:518-480-8117
Mailing Address - Fax:
Practice Address - Street 1:2155 STATE ROUTE 22B
Practice Address - Street 2:
Practice Address - City:MORRISONVILLE
Practice Address - State:NY
Practice Address - Zip Code:12962-3417
Practice Address - Country:US
Practice Address - Phone:518-563-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008344101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health