Provider Demographics
NPI:1174914808
Name:FORTIN, SAMANTHA (LMSW)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:FORTIN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:CLOUTIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13213 E 14 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-6302
Mailing Address - Country:US
Mailing Address - Phone:586-939-4374
Mailing Address - Fax:586-939-4783
Practice Address - Street 1:13213 E 14 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-6302
Practice Address - Country:US
Practice Address - Phone:586-939-4374
Practice Address - Fax:586-939-4783
Is Sole Proprietor?:No
Enumeration Date:2015-02-17
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 247200000X
MI6801102790104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801102790OtherLLMSW LICENSE NUMBER
MI6801108455OtherLMSW LICENSE NUMBER