Samuel Austin Formanek

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

P107181 Issued in NY

Practice address

248 W 108TH St
New York, NY 10025-2956

Phone

(212) 663-3000

NPI assigned

Oct 16, 2020

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Other identifiers 2

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

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

{
    "created_epoch": "1602806400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1701043200000",
    "number": "1811595259",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "41 CORELL RD",
            "city": "SCARSDALE",
            "state": "NY",
            "postal_code": "105837448",
            "telephone_number": "191-484-4297"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "248 W 108TH ST",
            "city": "NEW YORK",
            "state": "NY",
            "postal_code": "100252956",
            "telephone_number": "212-663-3000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FORMANEK",
        "first_name": "SAMUEL",
        "middle_name": "AUSTIN",
        "name_prefix": "Mr.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2020-10-16",
        "last_updated": "2023-11-27",
        "certification_date": "2020-10-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "NY",
            "license": "P107181",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NY STATE LICENSE PERMIT",
            "identifier": "P107181",
            "state": "NY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "P107181",
            "state": "NY"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "sformanek@thenbridgeny.org",
            "affiliation": "Y",
            "affiliationName": "The Bridge, Inc.",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "248 W 108th St",
            "city": "New York",
            "state": "NY",
            "country_code": "US",
            "postal_code": "100252956",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Marjorie Forman, LCSW LP
• Nancy Forman, M.D.
• Rachel Forman, PSYD
• Robin Nancy Forman, PH.D.
• Tamar Forman, GENETIC COUNSELOR
• Karen Formato, MS, RD, CDN
• Forme Dental PLLC
• Aisha Z. Formentera, RN
• Silvia C. Formenti, M.D.
• Michael Pasquale Formica, PA

• Mental Health Counselor in New York, NY
• Providers in New York, NY by specialty
• Mental Health Counselor in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 27, 2023; 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.