Provider Demographics
NPI:1871069419
Name:SAMUELS, EBONY
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:SAMUELS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12146 POND PINE DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-4475
Mailing Address - Country:US
Mailing Address - Phone:352-942-5151
Mailing Address - Fax:
Practice Address - Street 1:18109 PRINCE PHILIP DR STE B200
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1591
Practice Address - Country:US
Practice Address - Phone:301-570-7415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDA5202225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program