Provider Demographics
NPI:1922243583
Name:DIETZ-SAMUDIO, JENNY (MASTER OF SCIENCE)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:DIETZ-SAMUDIO
Suffix:
Gender:F
Credentials:MASTER OF SCIENCE
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:
Other - Last Name:DIETZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MASTER OF SCIENCE
Mailing Address - Street 1:3571 BUNKER AVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793
Mailing Address - Country:US
Mailing Address - Phone:718-454-3584
Mailing Address - Fax:
Practice Address - Street 1:184-10 JAMACA AVE
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423
Practice Address - Country:US
Practice Address - Phone:718-454-3584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist