MEDICARE: SARAH JANE HOWARD SAMUELS LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	16137	MN

General Provider Information

NPI Number	:	1063636413
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH JANE HOWARD SAMUELS LICSW

Provider Business Mailing Address
First Line	:	3208 31ST AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-2046
Country	:	US
Telephone Number	:	612-702-3947
Fax Number	:

Provider Business Practice Location Address
First Line	:	3208 31ST AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-2046
Country	:	US
Telephone Number	:	612-702-3947
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	07/08/2007

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