Basic Information
| Provider Information | |||||||||
| NPI: | 1417939372 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMUELS | ||||||||
| FirstName: | BENNETT | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 E 15TH ST | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324055412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505224485 | ||||||||
| FaxNumber: | 8509146281 | ||||||||
| Practice Location | |||||||||
| Address1: | 4094 LAFAYETTE ST | ||||||||
| Address2: | |||||||||
| City: | MARIANNA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324465648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504827441 | ||||||||
| FaxNumber: | 8509148261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | SW 0003879 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.