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General NPI Number Information
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NPI Number | 1275576241
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Entity Type | Individual
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Provider Name | ETTALEE SAMEK PASS PH.D.
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Gender | Female
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Dates
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Enumeration Date | 06/14/2006
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Last Update Date | 02/07/2010
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Provider Practice Location Address
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Address Line | 29 MANOR RD
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City | SMITHTOWN
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State | NY
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Zip | 11787-2714
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Country | US
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Telephone | 631-265-8873
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Fax | 631-751-5287
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Provider Business Mailing Address
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Address Line | 29 MANOR RD
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City | SMITHTOWN
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State | NY
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Zip | 11787-2752
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Country | US
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Telephone | 631-265-8873
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Fax | 631-751-5287
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 011597
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License Number State | NY
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