Provider Demographics
NPI:1588116545
Name:SAMUELSON, DINAH (LAC)
Entity type:Individual
Prefix:
First Name:DINAH
Middle Name:
Last Name:SAMUELSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2527 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-3322
Mailing Address - Country:US
Mailing Address - Phone:614-279-2525
Mailing Address - Fax:
Practice Address - Street 1:2527 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204
Practice Address - Country:US
Practice Address - Phone:614-279-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001182171100000X
OH65.000352171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist