Provider Demographics
NPI:1861636631
Name:SAMUEL, IGNATIUS A (LCSW)
Entity Type:Individual
Prefix:MR
First Name:IGNATIUS
Middle Name:A
Last Name:SAMUEL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 DOVER ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-3931
Mailing Address - Country:US
Mailing Address - Phone:401-274-0881
Mailing Address - Fax:
Practice Address - Street 1:1007 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYVILLE
Practice Address - State:CT
Practice Address - Zip Code:06241-2170
Practice Address - Country:US
Practice Address - Phone:860-774-2020
Practice Address - Fax:860-774-0095
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICSW005791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical