Provider Demographics
NPI:1649903287
Name:SAMUELS, KERRINE A
Entity type:Individual
Prefix:
First Name:KERRINE
Middle Name:A
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10408 150TH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-4927
Mailing Address - Country:US
Mailing Address - Phone:917-291-9671
Mailing Address - Fax:
Practice Address - Street 1:10408 150TH ST APT 3R
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-4938
Practice Address - Country:US
Practice Address - Phone:917-291-9671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY116005104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY981858045OtherNEW YORK STATE DRIVER'S LICENSE