Basic Information
| Provider Information | |||||||||
| NPI: | 1215969514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMUELS | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | ERIC | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4545 S 86TH ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685269227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024836990 | ||||||||
| FaxNumber: | 4024837045 | ||||||||
| Practice Location | |||||||||
| Address1: | 4545 S 86TH ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685269227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024836990 | ||||||||
| FaxNumber: | 4024837045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 624 | NE | X | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103T00000X | 624 | NE | X | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 624 | NE | X | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TF0200X | 624 | NE | X | Behavioral Health & Social Service Providers | Psychologist | Forensic |
ID Information
| ID | Type | State | Issuer | Description | 10024969000 | 05 | NE | MEDICAID | 47079871700 | 05 | NE | MEDICAID | 10024968900 | 05 | NE | MEDICAID | 470798717-26 | 05 | NE | MEDICAID | 470798717-27 | 05 | NE | MEDICAID | 470798717-29 | 05 | NE | MEDICAID | 246565 | 01 | NE | MIDLANDS CHOICE | OTHER | D80001 | 01 | NE | BCBS | OTHER |