Provider Demographics
NPI:1750748687
Name:SAMUEL, ERICA JUSTINE (LMSW)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:JUSTINE
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 SEQUOIA NW
Mailing Address - Street 2:APT F-21
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-9547
Mailing Address - Country:US
Mailing Address - Phone:575-993-1364
Mailing Address - Fax:
Practice Address - Street 1:6101 SEQUOIA RD NW
Practice Address - Street 2:APT F-21
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-3412
Practice Address - Country:US
Practice Address - Phone:575-993-1364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-22
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-06131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical