Provider Demographics
NPI:1669966438
Name:PEARSALL, SAMMANTHA TAYLOR
Entity type:Individual
Prefix:
First Name:SAMMANTHA
Middle Name:TAYLOR
Last Name:PEARSALL
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 1:32 AWIXA AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8802
Mailing Address - Country:US
Mailing Address - Phone:631-275-7793
Mailing Address - Fax:
Practice Address - Street 1:37 - 11 35TH AVE
Practice Address - Street 2:SUITE 3C
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11101
Practice Address - Country:US
Practice Address - Phone:718-706-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103510-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker