Individual
MARLENE Y SAMUELS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MED-WAIVER PROVIDER
Contact information
Practice address
4241 SW HAGAPLAN ST, PORT ST LUCIE, FL 34953-6583
(772) 224-4466
Mailing address
4241 SW HAGAPLAN ST, PORT ST LUCIE, FL 34953-6583
(772) 224-4466
Taxonomy
Speciality
Code
Description
License number
State
261QD1600X
Developmental Disabilities Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
261QD1600X
—
FL
Enumeration date
11/21/2017
Last updated
11/21/2017
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