Provider Demographics
NPI:1235607623
Name:VASQUEZ, SAMANTHA (LCAQ)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:LCAQ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUSTAVE L LEVY PL
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6504
Mailing Address - Country:US
Mailing Address - Phone:212-241-6880
Mailing Address - Fax:646-537-8929
Practice Address - Street 1:1468 MADISON AVE. ANNENBERG BUILDING, 4TH FLOOR
Practice Address - Street 2:BLAU CENTER FOR CHILDREN'S CANCER AND BLOOD DISEASE
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:212-241-6880
Practice Address - Fax:646-537-8929
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY086848-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical