Samantha Renee Pelcak, PH.D.

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

PSY-004732 Issued in AZ

Practice address

11050 Mount Belvedere Blvd
Fort Drum, NY 13602-5438

Phone

(315) 772-0215

NPI assigned

Jan 25, 2017

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Dr. Samantha Renee Jesse Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Doctor of Philosophy

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1485302400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1731369600000",
    "number": "1497292619",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11050 MOUNT BELVEDERE BLVD",
            "city": "FORT DRUM",
            "state": "NY",
            "postal_code": "136025438",
            "telephone_number": "315-772-0215"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11050 MOUNT BELVEDERE BLVD",
            "city": "FORT DRUM",
            "state": "NY",
            "postal_code": "136025438",
            "telephone_number": "315-772-0215"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PELCAK",
        "first_name": "SAMANTHA",
        "middle_name": "RENEE",
        "name_prefix": "Dr.",
        "credential": "PH.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2017-01-25",
        "last_updated": "2024-11-12",
        "certification_date": "2024-11-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "AZ",
            "license": "PSY-004732",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "SAMANTHA",
            "last_name": "JESSE",
            "middle_name": "RENEE",
            "prefix": "DR.",
            "credential": "PH.D.",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Eleanor Park
• Gregory John Pataky, APA-C
• David Andrew Paul
• Dean C Pedersen, M.D.
• Gregory H Pelcak, P.A.
• Tanya Monique Perez, PA
• Brandon Anthony Perroots, DDS
• Jennifer Louise Petersen, NURSE PRACTITIONER
• Renee Jean Petitto, D.C
• Maria Pettit

• Clinical Psychologist in Fort Drum, NY
• Providers in Fort Drum, NY by specialty
• Clinical Psychologist in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 12, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.