1619291465 NPI number — DR. SAMANTHA JANE GORDON FULD LCSW-C

Table of content: DR. SAMANTHA JANE GORDON FULD LCSW-C (NPI 1619291465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619291465 NPI number — DR. SAMANTHA JANE GORDON FULD LCSW-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULD
Provider First Name:
SAMANTHA
Provider Middle Name:
JANE GORDON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619291465
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1238 TOWSON ST APT 3E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21230-5326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-751-1087
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1238 TOWSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21230-5326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-751-1087
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/23/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  081546 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 22368 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com