Provider Demographics
NPI:1730310129
Name:KEROLOS, SAMIR WASFY (MA)
Entity Type:Individual
Prefix:MR
First Name:SAMIR
Middle Name:WASFY
Last Name:KEROLOS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3761 MANITOBA WAY
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-6075
Mailing Address - Country:US
Mailing Address - Phone:321-427-3988
Mailing Address - Fax:
Practice Address - Street 1:1037 PATHFINDER WAY STE 130
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3242
Practice Address - Country:US
Practice Address - Phone:321-639-1224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-03
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health