Provider Demographics
NPI:1548542483
Name:CARLISLE, SAMUEL EMERSON (LCSW)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:EMERSON
Last Name:CARLISLE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4530 BROADWAY 4E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040
Mailing Address - Country:US
Mailing Address - Phone:917-327-2025
Mailing Address - Fax:
Practice Address - Street 1:4530 BROADWAY 4E
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040
Practice Address - Country:US
Practice Address - Phone:917-327-2025
Practice Address - Fax:718-396-6189
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0842191104100000X
NY90166021041C0700X
NY0834651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker