Provider Demographics
NPI:1760239701
Name:BAGWANDEEN, SAMANTHA-JEAN
Entity type:Individual
Prefix:
First Name:SAMANTHA-JEAN
Middle Name:
Last Name:BAGWANDEEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 BEACH 69TH ST
Mailing Address - Street 2:
Mailing Address - City:ARVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11692-1426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 BEACH 69TH ST
Practice Address - Street 2:
Practice Address - City:ARVERNE
Practice Address - State:NY
Practice Address - Zip Code:11692-1426
Practice Address - Country:US
Practice Address - Phone:347-323-7511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1622585221103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist