Provider Demographics
NPI:1912030891
Name:SAMUELS, JONATHAN (PSYD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:SAMUELS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 GRACE AVE
Mailing Address - Street 2:SUITE 8C
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-2447
Mailing Address - Country:US
Mailing Address - Phone:516-482-4715
Mailing Address - Fax:
Practice Address - Street 1:10 GRACE AVE
Practice Address - Street 2:SUITE 8C
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-2447
Practice Address - Country:US
Practice Address - Phone:516-482-4715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10849103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist