Provider Demographics
NPI:1710756978
Name:MOHAMMAD, SAMIRA
Entity Type:Individual
Prefix:
First Name:SAMIRA
Middle Name:
Last Name:MOHAMMAD
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 1:205 LIDO PKWY
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-6022
Mailing Address - Country:US
Mailing Address - Phone:917-498-0808
Mailing Address - Fax:
Practice Address - Street 1:3 HYNES CT
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-2259
Practice Address - Country:US
Practice Address - Phone:516-531-3673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRBT-23-312131106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician