Healthcare Provider Details

I. General information

NPI: 1992291702
Provider Name (Legal Business Name): SAMANTHA TRIMBLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2018
Last Update Date: 08/19/2024
Certification Date: 08/12/2024
Deactivation Date: 03/21/2019
Reactivation Date: 04/03/2019

III. Provider practice location address

7375 WOODWARD AVE STE 2800
DETROIT MI
48202-3157
US

IV. Provider business mailing address

100 N PACIFIC COAST HWY STE 1400
EL SEGUNDO CA
90245-5602
US

V. Phone/Fax

Practice location:
  • Phone: 313-251-6367
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401001455
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: