Basic Information
Provider Information | |||||||||
NPI: | 1275173536 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WOLDE | ||||||||
FirstName: | SAMUEL | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10428 W COLTER ST | ||||||||
Address2: |   | ||||||||
City: | GLENDALE | ||||||||
State: | AZ | ||||||||
PostalCode: | 853074195 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7202267900 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4635 SOUTHWEST FWY STE 635 | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770277112 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7138500049 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/14/2020 | ||||||||
LastUpdateDate: | 09/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 18390 |   | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | 39274 | TX | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.