Provider Demographics
NPI:1992067755
Name:SAMUELS, STACY ANN (MSED)
Entity type:Individual
Prefix:
First Name:STACY ANN
Middle Name:
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 METROPOLITAN OVAL
Mailing Address - Street 2:#3F
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-6523
Mailing Address - Country:US
Mailing Address - Phone:718-822-3873
Mailing Address - Fax:
Practice Address - Street 1:8 EVERGREEN CIR
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-2214
Practice Address - Country:US
Practice Address - Phone:773-217-4907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY134293071174400000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174400000XOther Service ProvidersSpecialist