=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992587745
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMARA FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2023
-----------------------------------------------------
Last Update Date | 10/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5587 MURRAY AVE STE 205
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38119-0896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-729-9767
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5587 MURRAY AVE STE 205
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38119-0896
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-729-9767
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRISA SAMUDIO
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 901-729-9767
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------