Provider Demographics
NPI:1063636413
Name:SAMUELS, SARAH JANE HOWARD (LICSW)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:JANE HOWARD
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 31ST AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-2046
Mailing Address - Country:US
Mailing Address - Phone:612-702-3947
Mailing Address - Fax:
Practice Address - Street 1:3208 31ST AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-2046
Practice Address - Country:US
Practice Address - Phone:612-702-3947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN161371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical