MEDICARE: DR. SAMANTHA GWEN FARRIS PHD

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	103TC0700X	Clinical Psychologist	PS01643	RI
2	103TC0700X	Clinical Psychologist	35SI00600200	NJ

General Provider Information

NPI Number	:	1467061051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMANTHA GWEN FARRIS PHD

Provider Business Mailing Address
First Line	:	56 SPRUCE ST APT B
Second Line	:
City	:	PRINCETON
State	:	NJ
Zip	:	08542-3812
Country	:	US
Telephone Number	:	908-229-8991
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 SPRING ST
Second Line	:
City	:	NEW BRUNSWICK
State	:	NJ
Zip	:	08901-2276
Country	:	US
Telephone Number	:	908-229-8991
Fax Number	:

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

Provider Enumeration Date	:	07/29/2020
Last Update Date	:	07/29/2020

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