Provider Demographics
NPI:1811483548
Name:SAMUELS, VANESSA
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
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 1:16224 N 154TH DR
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-7416
Mailing Address - Country:US
Mailing Address - Phone:602-283-7117
Mailing Address - Fax:
Practice Address - Street 1:16224 N 154TH DR
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7416
Practice Address - Country:US
Practice Address - Phone:602-283-7117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child