Provider Demographics
NPI:1497330666
Name:SAMUEL, LATOYA (HLPC, RC, RCI)
Entity Type:Individual
Prefix:MS
First Name:LATOYA
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:HLPC, RC, RCI
Other - Prefix:PROF
Other - First Name:LATOYA
Other - Middle Name:
Other - Last Name:SAMUEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RC61285, RCI 35267
Mailing Address - Street 1:1220 BOWER PKWY STE E5
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-3729
Mailing Address - Country:US
Mailing Address - Phone:803-206-9568
Mailing Address - Fax:
Practice Address - Street 1:1220 BOWER PKWY STE E5
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-3729
Practice Address - Country:US
Practice Address - Phone:803-206-9568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-10
Last Update Date:2021-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC612851744P3200X
SC335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC61285OtherCOSMETOLOGY
SC35267OtherCOSMETOLOGY INSTRUCTOR
SC7247OtherHAIR LOSS PRACTIONER CERTIFICATION