Provider Demographics
NPI:1962144493
Name:SAMUEL, MARTHA (LMHC)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3561 FOREST VIEW CIR
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-6304
Mailing Address - Country:US
Mailing Address - Phone:305-965-6802
Mailing Address - Fax:
Practice Address - Street 1:2421 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-6605
Practice Address - Country:US
Practice Address - Phone:305-965-6802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH20656101YM0800X
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health