Provider Demographics
NPI:1811595259
Name:FORMANEK, SAMUEL AUSTIN
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:AUSTIN
Last Name:FORMANEK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 CORELL RD
Mailing Address - Street 2:
Mailing Address - City:SCARSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10583-7448
Mailing Address - Country:US
Mailing Address - Phone:191-484-4297
Mailing Address - Fax:
Practice Address - Street 1:248 W 108TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-2956
Practice Address - Country:US
Practice Address - Phone:212-663-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP107181101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP107181OtherNY STATE LICENSE PERMIT
NYP107181Medicaid