Provider Demographics
NPI:1669743076
Name:SAMUELS, TINA MARIE (LMSW)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:SHIRTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2809 FOREST HOME RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5320
Mailing Address - Country:US
Mailing Address - Phone:866-972-1268
Mailing Address - Fax:
Practice Address - Street 1:112 N BETTIS ST
Practice Address - Street 2:
Practice Address - City:POCAHONTAS
Practice Address - State:AR
Practice Address - Zip Code:72455-3301
Practice Address - Country:US
Practice Address - Phone:870-609-0034
Practice Address - Fax:870-609-0036
Is Sole Proprietor?:No
Enumeration Date:2012-01-16
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6863-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR190302795Medicaid