Provider Demographics
NPI:1205392313
Name:VUNDLA, SAMKELE (LCSW)
Entity Type:Individual
Prefix:
First Name:SAMKELE
Middle Name:
Last Name:VUNDLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 REISTERSTOWN RD STE 101
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-5330
Mailing Address - Country:US
Mailing Address - Phone:410-358-1111
Mailing Address - Fax:
Practice Address - Street 1:300 REISTERSTOWN RD STE 101
Practice Address - Street 2:
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-5330
Practice Address - Country:US
Practice Address - Phone:410-358-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD192451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical