Provider Demographics
NPI:1275576241
Name:PASS, ETTALEE SAMEK (PHD)
Entity Type:Individual
Prefix:DR
First Name:ETTALEE
Middle Name:SAMEK
Last Name:PASS
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 1:29 MANOR RD
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2752
Mailing Address - Country:US
Mailing Address - Phone:631-265-8873
Mailing Address - Fax:631-751-5287
Practice Address - Street 1:29 MANOR RD
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2714
Practice Address - Country:US
Practice Address - Phone:631-265-8873
Practice Address - Fax:631-751-5287
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2010-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011597103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV01201Medicare ID - Type Unspecified