Healthcare Provider Details

I. General information

NPI: 1861780652
Provider Name (Legal Business Name): CLARA R SAM CT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2011
Last Update Date: 07/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

TETLIN VILLAGE ROAD
TETLIN AK
99780
US

IV. Provider business mailing address

PO BOX 597
TOK AK
99780-0597
US

V. Phone/Fax

Practice location:
  • Phone: 907-324-2136
  • Fax: 907-324-2136
Mailing address:
  • Phone: 907-324-2136
  • Fax: 907-883-2136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: