Healthcare Provider Details

I. General information

NPI: 1164294971
Provider Name (Legal Business Name): EMILY SAMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2023
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3835 EDISON LAKES PKWY STE 200
MISHAWAKA IN
46545-3462
US

IV. Provider business mailing address

3835 EDISON LAKES PKWY STE 200
MISHAWAKA IN
46545-3462
US

V. Phone/Fax

Practice location:
  • Phone: 574-210-0303
  • Fax:
Mailing address:
  • Phone: 574-210-0303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number99121443A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: