Provider Demographics
NPI:1932604956
Name:SAMUELS, DOMINIQUE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
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 1:1200 1ST ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-3361
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6201 5TH ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-1336
Practice Address - Country:US
Practice Address - Phone:202-576-6156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-30
Last Update Date:2024-08-28
Deactivation Date:2021-09-08
Deactivation Code:
Reactivation Date:2021-09-23
Provider Licenses
StateLicense IDTaxonomies
DCOT210002224225X00000X
MD09421225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist