Provider Demographics
NPI:1386193282
Name:WHITE-SAMUELS, NICOLE (LGSW)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:WHITE-SAMUELS
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 WALNUT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21221-6061
Mailing Address - Country:US
Mailing Address - Phone:410-365-3431
Mailing Address - Fax:
Practice Address - Street 1:705 WALNUT GROVE RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21221-6061
Practice Address - Country:US
Practice Address - Phone:410-365-3431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19200104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker