Provider Demographics
NPI:1407227879
Name:SAMUEL, KIBASA (LCSW, CASAC, SAP MAC)
Entity Type:Individual
Prefix:MS
First Name:KIBASA
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:LCSW, CASAC, SAP MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 COMMACK RD # 1010
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-3442
Mailing Address - Country:US
Mailing Address - Phone:516-430-7372
Mailing Address - Fax:
Practice Address - Street 1:169 COMMACK RD # 1010
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-3442
Practice Address - Country:US
Practice Address - Phone:516-430-7372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-12
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY31589101YA0400X
NY4937560101YP2500X
NY72091813104100000X
NY0902321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker