Provider Demographics
NPI:1386238954
Name:SAMUEL, RACQUEL
Entity type:Individual
Prefix:
First Name:RACQUEL
Middle Name:
Last Name:SAMUEL
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 1:1251 BROOKLYN AVE # 2R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-5517
Mailing Address - Country:US
Mailing Address - Phone:347-859-6571
Mailing Address - Fax:
Practice Address - Street 1:303 5TH AVE RM 1909
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6658
Practice Address - Country:US
Practice Address - Phone:212-545-9901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111613-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker