Provider Demographics
NPI:1275173536
Name:WOLDE, SAMUEL A
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:A
Last Name:WOLDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10428 W COLTER ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85307-4195
Mailing Address - Country:US
Mailing Address - Phone:720-226-7900
Mailing Address - Fax:
Practice Address - Street 1:4635 SOUTHWEST FWY STE 635
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-7112
Practice Address - Country:US
Practice Address - Phone:713-850-0049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
18390101YM0800X
TX39274103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health