Basic Information
| Provider Information | |||||||||
| NPI: | 1831390855 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARUSO | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | GWYNNE | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 CAREY RD | ||||||||
| Address2: | |||||||||
| City: | QUEENSBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128047880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187610300 | ||||||||
| FaxNumber: | 5188242388 | ||||||||
| Practice Location | |||||||||
| Address1: | 161 CAREY RD | ||||||||
| Address2: | |||||||||
| City: | QUEENSBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128047821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188248160 | ||||||||
| FaxNumber: | 5188242390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 01/30/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 017452 | NY | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 04271743 | 05 | NY | MEDICAID |