MEDICARE: JONATHAN SAMUELS PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	10849	NY

General Provider Information

NPI Number	:	1912030891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN SAMUELS PSYD

Provider Business Mailing Address
First Line	:	10 GRACE AVE
Second Line	:	SUITE 8C
City	:	GREAT NECK
State	:	NY
Zip	:	11021-2447
Country	:	US
Telephone Number	:	516-482-4715
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 GRACE AVE
Second Line	:	SUITE 8C
City	:	GREAT NECK
State	:	NY
Zip	:	11021-2447
Country	:	US
Telephone Number	:	516-482-4715
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	01/14/2013

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