Provider Demographics
NPI:1558732206
Name:OKANUME, SAM
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:OKANUME
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 CALVERTON BLVD APT 21
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-3406
Mailing Address - Country:US
Mailing Address - Phone:301-814-3764
Mailing Address - Fax:301-459-0297
Practice Address - Street 1:8301 PROFESSIONAL PL STE 205
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20785-2353
Practice Address - Country:US
Practice Address - Phone:301-552-7120
Practice Address - Fax:301-459-0297
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDPRC14657101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCPRC14657OtherPROFESSIONAL LICENSE