Provider Demographics
NPI:1588851893
Name:SAMUELS COLE, STACEY (AUD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
Last Name:SAMUELS COLE
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19110 MONTGOMERY VILLAGE AVE
Mailing Address - Street 2:STE 120
Mailing Address - City:MONTGOMERY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-3706
Mailing Address - Country:US
Mailing Address - Phone:301-977-6317
Mailing Address - Fax:
Practice Address - Street 1:4801 DORSEY HALL DR STE 135
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7763
Practice Address - Country:US
Practice Address - Phone:410-885-6700
Practice Address - Fax:410-885-6821
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01050231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD193403100Medicaid
DCG00024Medicare PIN