Provider Demographics
NPI:1912415621
Name:SAMUELL, WENDY
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:SAMUELL
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 1:15231 SW 80TH ST APT 302
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-1358
Mailing Address - Country:US
Mailing Address - Phone:786-759-8528
Mailing Address - Fax:
Practice Address - Street 1:15231 SW 80TH ST APT 302
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-1358
Practice Address - Country:US
Practice Address - Phone:786-238-0513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18-60944106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021292400Medicaid