Provider Demographics
NPI:1609685452
Name:SAMUEL, STACY (PMHNP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4413 BORA BORA LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77045-1735
Mailing Address - Country:US
Mailing Address - Phone:832-290-8518
Mailing Address - Fax:
Practice Address - Street 1:7877 WILLOW CHASE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-5934
Practice Address - Country:US
Practice Address - Phone:833-777-9247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1182151363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health