Provider Demographics
NPI:1427805241
Name:SAMUELS, KATRINA SABRINA
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:SABRINA
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 1:3903 GENACRE LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23222-1731
Mailing Address - Country:US
Mailing Address - Phone:804-852-4895
Mailing Address - Fax:
Practice Address - Street 1:3903 GENACRE LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23222-1731
Practice Address - Country:US
Practice Address - Phone:804-852-4895
Practice Address - Fax:804-486-6620
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-30
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities