=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699355636
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OFFICE OF CARMELITA R SAMUEL,MSW PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2021
-----------------------------------------------------
Last Update Date | 04/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1130 TIENKEN CT STE 233
-----------------------------------------------------
City | ROCHESTER HLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48306-4367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-291-7216
-----------------------------------------------------
Fax | 248-221-5518
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1130 TIENKEN CT STE 223
-----------------------------------------------------
City | ROCHESTER HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48306-4370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-291-7216
-----------------------------------------------------
Fax | 248-221-5518
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PROF. CARMELITA REYES SAMUEL
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 248-291-7216
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------