Provider Demographics
NPI:1497292619
Name:PELCAK, SAMANTHA RENEE (PHD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RENEE
Last Name:PELCAK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:RENEE
Other - Last Name:JESSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:11050 MOUNT BELVEDERE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5438
Mailing Address - Country:US
Mailing Address - Phone:315-772-0215
Mailing Address - Fax:
Practice Address - Street 1:11050 MOUNT BELVEDERE BLVD
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5438
Practice Address - Country:US
Practice Address - Phone:315-772-0215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4732103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical