MEDICARE: SAMANTHA C OMELIAN PH.D.

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	PY12029	FL

General Provider Information

NPI Number	:	1982089140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA C OMELIAN PH.D.

Provider Business Mailing Address
First Line	:	2803 GULF TO BAY BLVD # 116
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33759-4014
Country	:	US
Telephone Number	:	727-210-5081
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 GULF TO BAY BLVD STE 300
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33759-4304
Country	:	US
Telephone Number	:	800-687-1938
Fax Number	:

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

Provider Enumeration Date	:	07/29/2015
Last Update Date	:	10/29/2024

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