Provider Demographics
NPI:1730955717
Name:SIMON, SAMANTHA ANN (MLP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANN
Last Name:SIMON
Suffix:
Gender:F
Credentials:MLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5708 VENTURE CT STE B
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-2858
Mailing Address - Country:US
Mailing Address - Phone:269-459-1818
Mailing Address - Fax:
Practice Address - Street 1:1009 44TH ST SW STE 103
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-4480
Practice Address - Country:US
Practice Address - Phone:269-459-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361007951103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist