Provider Demographics
NPI:1629845292
Name:GADSDEN, SAMARA JOY I
Entity Type:Individual
Prefix:
First Name:SAMARA
Middle Name:JOY
Last Name:GADSDEN
Suffix:I
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 1:168 CLINTON AVE APT 12
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304-2450
Mailing Address - Country:US
Mailing Address - Phone:134-754-7968
Mailing Address - Fax:
Practice Address - Street 1:2381 HYLAN BLVD STE 13
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-3145
Practice Address - Country:US
Practice Address - Phone:800-277-4680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY105816-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker