Provider Demographics
NPI:1275786832
Name:SAMUEL, SUSAN BA (PD,SAS, SDA, MSED)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:BA
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:PD,SAS, SDA, MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12722 HAWTREE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-1632
Mailing Address - Country:US
Mailing Address - Phone:917-324-7592
Mailing Address - Fax:347-644-5737
Practice Address - Street 1:12722 HAWTREE CREEK RD
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420-1632
Practice Address - Country:US
Practice Address - Phone:917-324-7592
Practice Address - Fax:347-644-5737
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist