Provider Demographics
NPI:1255563854
Name:SAMUELSON, CLARA M
Entity type:Individual
Prefix:
First Name:CLARA
Middle Name:M
Last Name:SAMUELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2649 TOWN CENTER BLVD N
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-2319
Mailing Address - Country:US
Mailing Address - Phone:832-886-5878
Mailing Address - Fax:218-565-2924
Practice Address - Street 1:2649 TOWN CENTER BLVD N
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-2319
Practice Address - Country:US
Practice Address - Phone:832-886-5878
Practice Address - Fax:218-565-2924
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-14
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12661101YP2500X
101YS0200X, 103K00000X, 103TB0200X, 103TM1800X, 171W00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No174400000XOther Service ProvidersSpecialist