Provider Demographics
NPI:1699194282
Name:SAMUELS, ELISSA (LCPC)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:
Last Name:SAMUELS
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:PO BOX 136
Mailing Address - Street 2:9701 KEYSVILLE ROAD, US ROUTE 15 AND KEYSVILLE ROAD
Mailing Address - City:EMMITSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21727-0136
Mailing Address - Country:US
Mailing Address - Phone:301-447-2361
Mailing Address - Fax:301-447-3715
Practice Address - Street 1:9701 KEYSVILLE RD
Practice Address - Street 2:US ROUTE 15 AND KEYSVILLE ROAD
Practice Address - City:EMMITSBURG
Practice Address - State:MD
Practice Address - Zip Code:21727-8619
Practice Address - Country:US
Practice Address - Phone:301-447-2361
Practice Address - Fax:301-447-3715
Is Sole Proprietor?:No
Enumeration Date:2014-04-10
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3747101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional