Provider Demographics
NPI:1790015212
Name:SAMARITAN LICENSED CLINICAL SOCIAL WORK, PC
Entity Type:Organization
Organization Name:SAMARITAN LICENSED CLINICAL SOCIAL WORK, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:VALIQUETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-374-3514
Mailing Address - Street 1:220 N BALLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-2533
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 N BALLSTON AVE
Practice Address - Street 2:
Practice Address - City:SCOTIA
Practice Address - State:NY
Practice Address - Zip Code:12302-2533
Practice Address - Country:US
Practice Address - Phone:518-374-3514
Practice Address - Fax:518-374-9193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP71596251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health