Healthcare Provider Details

I. General information

NPI: 1477418572
Provider Name (Legal Business Name): ANTHONY DEWAYNE SAMUEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7831 CASPIAN BAY DRIVE
CONVERSE TX
78109
US

IV. Provider business mailing address

7831 CASPIAN BAY DRIVE
CONVERSE TX
78109
US

V. Phone/Fax

Practice location:
  • Phone: 210-305-2127
  • Fax:
Mailing address:
  • Phone: 210-305-2127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number117609
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: