Provider Demographics
NPI:1639985252
Name:SAMUELS, EBONI DEE
Entity type:Individual
Prefix:
First Name:EBONI
Middle Name:DEE
Last Name:SAMUELS
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 1:945 NW NAITO PKWY APT 535
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-4718
Mailing Address - Country:US
Mailing Address - Phone:916-271-0685
Mailing Address - Fax:
Practice Address - Street 1:14355 N BYBEE LAKE CT
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-6495
Practice Address - Country:US
Practice Address - Phone:971-716-3309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-09
Last Update Date:2024-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator