Provider Demographics
NPI:1841396884
Name:SAMARITAN LICENSED CLINICAL SOCIAL WORK, PC
Entity Type:Organization
Organization Name:SAMARITAN LICENSED CLINICAL SOCIAL WORK, PC
Other - Org Name:SAMARITAN COUNSELING CENTER OF THE CAPITAL REGION, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
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 NORTH BALLSTON AVENUE
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:518-374-3514
Mailing Address - Fax:518-374-9193
Practice Address - Street 1:220 NORTH BALLSTON AVENUE
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:2006-09-16
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY52171AMedicare ID - Type Unspecified
NY52171AMedicare PIN