Healthcare Provider Details

I. General information

NPI: 1841673100
Provider Name (Legal Business Name): SAMANTHA DENBOER M.S., PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA KOEPPEL M.S., PSY.D.

II. Dates (important events)

Enumeration Date: 07/06/2015
Last Update Date: 11/12/2023
Certification Date: 11/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 MATTHEW DR
FORT MYERS FL
33907-1734
US

IV. Provider business mailing address

1555 MATTHEW DR
FORT MYERS FL
33907-1734
US

V. Phone/Fax

Practice location:
  • Phone: 239-533-9860
  • Fax:
Mailing address:
  • Phone: 239-533-9860
  • Fax: 239-533-9860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPY9315
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY9315
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: