Provider Demographics
NPI:1174037592
Name:SAMUELS, MARLENE Y (MED-WAIVER PROVIDER)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:Y
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:MED-WAIVER PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4241 SW HAGAPLAN ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-6583
Mailing Address - Country:US
Mailing Address - Phone:772-224-4466
Mailing Address - Fax:
Practice Address - Street 1:4241 SW HAGAPLAN ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-6583
Practice Address - Country:US
Practice Address - Phone:772-224-4466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261QD1600XMedicaid