MEDICARE: KIMBERLY SAMUELS

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	101Y00000X	Counselor	IMH 9022	FL

General Provider Information

NPI Number	:	1104359355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY SAMUELS

Provider Business Mailing Address
First Line	:	1503 GREENWOOD AVE
Second Line	:
City	:	LEHIGH ACRES
State	:	FL
Zip	:	33972-1627
Country	:	US
Telephone Number	:	863-234-1124
Fax Number	:

Provider Business Practice Location Address
First Line	:	1503 GREENWOOD AVE
Second Line	:
City	:	LEHIGH ACRES
State	:	FL
Zip	:	33972-1627
Country	:	US
Telephone Number	:	863-234-1124
Fax Number	:

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

Provider Enumeration Date	:	04/05/2017
Last Update Date	:	04/05/2017

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Directions to “ KIMBERLY SAMUELS ” Practice Location

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