Provider Demographics
NPI:1295212579
Name:BADER, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BADER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:KRAVITZ
Other - Suffix:
Other - Last Name Type:Former Name
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:212-256-2904
Mailing Address - Fax:
Practice Address - Street 1:1 GUSTAVE L LEVY PL
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6504
Practice Address - Country:US
Practice Address - Phone:212-256-2904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103847104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00243509Medicaid