Provider Demographics
NPI:1578226452
Name:WATT, SAMANTHA CUMMINS
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:CUMMINS
Last Name:WATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD LANDING
Mailing Address - State:NY
Mailing Address - Zip Code:11547-0158
Mailing Address - Country:US
Mailing Address - Phone:516-428-3562
Mailing Address - Fax:
Practice Address - Street 1:300 GARDEN CITY PLZ STE 350
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-3358
Practice Address - Country:US
Practice Address - Phone:516-428-3562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1000805103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool