Provider Demographics
NPI:1891030771
Name:TETENBAUM, SAMARA P (PHD)
Entity Type:Individual
Prefix:
First Name:SAMARA
Middle Name:P
Last Name:TETENBAUM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SAMARA
Other - Middle Name:
Other - Last Name:PULVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1760 HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-4429
Mailing Address - Country:US
Mailing Address - Phone:516-662-5013
Mailing Address - Fax:
Practice Address - Street 1:1 EXPRESSWAY PLZ
Practice Address - Street 2:SUITE 106
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577-2047
Practice Address - Country:US
Practice Address - Phone:516-621-2681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019474103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical