Healthcare Provider Details

I. General information

NPI: 1225687379
Provider Name (Legal Business Name): SAMARA LIPSKY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2019
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 GRAND ST
NEW YORK NY
10002-4800
US

IV. Provider business mailing address

465 GRAND ST
NEW YORK NY
10002-4800
US

V. Phone/Fax

Practice location:
  • Phone: 212-420-1970
  • Fax:
Mailing address:
  • Phone: 212-420-1970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: