Provider Demographics
NPI:1902360860
Name:SAMUELS, KATRINA
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5140 KARLING PL
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93552-4572
Mailing Address - Country:US
Mailing Address - Phone:661-492-1989
Mailing Address - Fax:
Practice Address - Street 1:5771 TRAMMELL RD. MORROW GA
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260
Practice Address - Country:US
Practice Address - Phone:661-492-1989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV175T00000X175T00000X
NV3747A0650X3747A0650X
NV374U000000X374U00000X
NV376K00000X376K00000X
NV106S0000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No175T00000XOther Service ProvidersPeer Specialist
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide