Provider Demographics
NPI:1023433646
Name:SAMUEL, ELDORNA (OTD)
Entity type:Individual
Prefix:DR
First Name:ELDORNA
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 RUNNING SAND KNL
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723-5783
Mailing Address - Country:US
Mailing Address - Phone:301-641-7035
Mailing Address - Fax:301-850-7613
Practice Address - Street 1:10000 RUNNING SAND KNL
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20723-5783
Practice Address - Country:US
Practice Address - Phone:301-641-7035
Practice Address - Fax:301-850-7613
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-19
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03803225XE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental Modification
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD510074700Medicaid