Provider Demographics
NPI:1730438581
Name:ELDRED, SAMANTHA LYNN (MA LLP CAADC)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:LYNN
Last Name:ELDRED
Suffix:
Gender:F
Credentials:MA LLP CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-3831
Mailing Address - Country:US
Mailing Address - Phone:248-965-6605
Mailing Address - Fax:
Practice Address - Street 1:117 W 3RD ST
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-3831
Practice Address - Country:US
Practice Address - Phone:248-965-6605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC-03096103TA0400X
MI6301015585103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)