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General NPI Number Information
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NPI Number | 1497591028
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Entity Type | Individual
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Provider Name | CHARLENE SAMUELS
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Gender | Female
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Dates
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Enumeration Date | 07/03/2024
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Last Update Date | 09/15/2024
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Provider Practice Location Address
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Address Line | 1495 DULUTH HWY STE F
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City | LAWRENCEVILLE
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State | GA
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Zip | 30043-5143
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Country | US
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Telephone | 321-352-9187
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Fax |
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Provider Business Mailing Address
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Address Line | 116 CHASE LANDING DR
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City | LOGANVILLE
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State | GA
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Zip | 30052-6523
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Country | US
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Telephone | 321-352-9187
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | MSW012018
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 9693
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License Number State | CT
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Taxonomy #3
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | 5260842
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CSW03862
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License Number State | RI
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