Provider Demographics
NPI:1750827663
Name:TOUSSAINT, SAMARA (PSYD)
Entity Type:Individual
Prefix:
First Name:SAMARA
Middle Name:
Last Name:TOUSSAINT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15350 89TH AVE APT 811
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-3885
Mailing Address - Country:US
Mailing Address - Phone:845-269-1190
Mailing Address - Fax:
Practice Address - Street 1:2351 JERUSALEM AVE
Practice Address - Street 2:
Practice Address - City:NORTH BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-1822
Practice Address - Country:US
Practice Address - Phone:516-608-6336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-17
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NY022519103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY17Medicaid