Provider Demographics
NPI:1285241208
Name:SAMUELSON, AUDREY (MS, CGC)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:SAMUELSON
Suffix:
Gender:F
Credentials:MS, CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8402 HARCOURT RD STE 300
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2052
Mailing Address - Country:US
Mailing Address - Phone:317-338-8983
Mailing Address - Fax:317-338-7154
Practice Address - Street 1:8402 HARCOURT RD STE 300
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2052
Practice Address - Country:US
Practice Address - Phone:317-338-8983
Practice Address - Fax:317-338-7154
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN74000352A170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS