Healthcare Provider Details

I. General information

NPI: 1467791830
Provider Name (Legal Business Name): YVONNE SAMPLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2013
Last Update Date: 02/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 PENINSULA BLVD
HEMPSTEAD NY
11550-4900
US

IV. Provider business mailing address

123 EMERY ST
HEMPSTEAD NY
11550-7428
US

V. Phone/Fax

Practice location:
  • Phone: 516-292-7111
  • Fax: 516-489-6492
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: