Healthcare Provider Details

I. General information

NPI: 1841396884
Provider Name (Legal Business Name): SAMARITAN LICENSED CLINICAL SOCIAL WORK, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 08/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 NORTH BALLSTON AVENUE
SCOTIA NY
12302-2533
US

IV. Provider business mailing address

220 NORTH BALLSTON AVENUE
SCOTIA NY
12302-2533
US

V. Phone/Fax

Practice location:
  • Phone: 518-374-3514
  • Fax: 518-374-9193
Mailing address:
  • Phone: 518-374-3514
  • Fax: 518-374-9193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH LEE VALIQUETTE
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 518-374-3514