Provider Demographics
NPI:1225718646
Name:SAMUEL, HEATHER (LCSW)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:SAMUEL
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 1:6091 NW 61ST AVE APT 312
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33319-6278
Mailing Address - Country:US
Mailing Address - Phone:195-447-9020
Mailing Address - Fax:
Practice Address - Street 1:6091 NW 61ST AVE APT 312
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33319-6278
Practice Address - Country:US
Practice Address - Phone:195-447-9020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW21697101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty