Provider Demographics
NPI:1679160501
Name:SAMUEL, MARY WANDA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:WANDA
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6827 WILLOW CREEK RUN
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-7416
Mailing Address - Country:US
Mailing Address - Phone:561-543-7311
Mailing Address - Fax:
Practice Address - Street 1:8785 SW 165TH AVE STE 104
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-5827
Practice Address - Country:US
Practice Address - Phone:786-206-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician