Provider Demographics
NPI:1447990718
Name:SAMUEL, KIM S (LPC)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:S
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 HIGHLAND AVE APT 401
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-1226
Mailing Address - Country:US
Mailing Address - Phone:347-869-1592
Mailing Address - Fax:
Practice Address - Street 1:212 HIGHLAND AVE APT 401
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-1226
Practice Address - Country:US
Practice Address - Phone:347-869-1592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-01
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00834800101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health