Provider Demographics
NPI:1720574221
Name:ALFRED, SAMUEL (CDCA)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:ALFRED
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1064 MARKHAM CT
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-6727
Mailing Address - Country:US
Mailing Address - Phone:419-265-0693
Mailing Address - Fax:
Practice Address - Street 1:5301 NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-4632
Practice Address - Country:US
Practice Address - Phone:419-531-5544
Practice Address - Fax:419-531-5117
Is Sole Proprietor?:No
Enumeration Date:2018-07-08
Last Update Date:2018-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.165458171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator