MEDICARE: MS. KIBASA SAMUEL LCSW, CASAC, SAP MAC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	31589	NY
2	101YP2500X	Professional Counselor	4937560	NY
3	104100000X	Social Worker	72091813	NY
4	1041C0700X	Clinical Social Worker	090232	NY

General Provider Information

NPI Number	:	1407227879
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIBASA SAMUEL LCSW, CASAC, SAP MAC

Provider Business Mailing Address
First Line	:	169 COMMACK RD # 1010
Second Line	:
City	:	COMMACK
State	:	NY
Zip	:	11725-3442
Country	:	US
Telephone Number	:	516-430-7372
Fax Number	:

Provider Business Practice Location Address
First Line	:	169 COMMACK RD # 1010
Second Line	:
City	:	COMMACK
State	:	NY
Zip	:	11725-3442
Country	:	US
Telephone Number	:	516-430-7372
Fax Number	:

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

Provider Enumeration Date	:	10/12/2015
Last Update Date	:	02/23/2022

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