Provider Demographics
NPI:1164281713
Name:SAMUEL, ELIZABETH (LICSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SAMUEL
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 1:8725 COLUMBINE RD UNIT 44046
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1385 NARCISSUS CURV
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:MN
Practice Address - Zip Code:55386-8506
Practice Address - Country:US
Practice Address - Phone:952-334-5080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN290631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical