Provider Demographics
NPI:1649752403
Name:SAMUDOVSKY, NATALIA (LCPC)
Entity Type:Individual
Prefix:
First Name:NATALIA
Middle Name:
Last Name:SAMUDOVSKY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12553 W EXPLORER DR STE 190
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1612
Mailing Address - Country:US
Mailing Address - Phone:208-376-7083
Mailing Address - Fax:208-321-5069
Practice Address - Street 1:12553 W EXPLORER DR STE 190
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1612
Practice Address - Country:US
Practice Address - Phone:208-376-7083
Practice Address - Fax:208-321-5069
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID6969101Y00000X
ID9023101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor