Provider Demographics
NPI:1447554183
Name:SAMUELS, DIANE (LMFT)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 PHEASANT CHASE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117
Mailing Address - Country:US
Mailing Address - Phone:860-841-0169
Mailing Address - Fax:
Practice Address - Street 1:12 N MAIN ST STE 10
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-1936
Practice Address - Country:US
Practice Address - Phone:869-841-0169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001410106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist