Provider Demographics
NPI:1689035016
Name:SAMUEL, THOMAS (CASAC-T)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:M
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 HAMILTON AVE
Mailing Address - Street 2:17 HAMILTON AVE
Mailing Address - City:MONTICELLO
Mailing Address - State:NY
Mailing Address - Zip Code:12701-1319
Mailing Address - Country:US
Mailing Address - Phone:845-794-8080
Mailing Address - Fax:
Practice Address - Street 1:17 HAMILTON AVE
Practice Address - Street 2:17 HAMILTON AVE
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-1319
Practice Address - Country:US
Practice Address - Phone:845-794-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-12
Last Update Date:2016-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY26641101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)