Provider Demographics
NPI:1710477328
Name:SAMUELS, JOHNETTA (MS, ALC)
Entity Type:Individual
Prefix:MS
First Name:JOHNETTA
Middle Name:
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:MS, ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7730 CREEKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695-4064
Mailing Address - Country:US
Mailing Address - Phone:251-423-9196
Mailing Address - Fax:
Practice Address - Street 1:7730 CREEKWOOD DR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-4064
Practice Address - Country:US
Practice Address - Phone:251-423-9196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC2955A101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional