Provider Demographics
NPI:1124788310
Name:SAMUELS, EDWARD L (LPCA)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:L
Last Name:SAMUELS
Suffix:
Gender:M
Credentials:LPCA
Other - Prefix:
Other - First Name:EDWARD
Other - Middle Name:
Other - Last Name:SAMUELS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPCA
Mailing Address - Street 1:PO BOX 11851
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40578-1851
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2079 GEORGIAN WAY # A
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3052
Practice Address - Country:US
Practice Address - Phone:859-552-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY267979101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health