Healthcare Provider Details

I. General information

NPI: 1710245683
Provider Name (Legal Business Name): SAMANTHA R WUNDERLICH CTRS, CBIS, CZT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 02/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

293 LEROY ST
FERNDALE MI
48220-1890
US

IV. Provider business mailing address

PO BOX 20274
FERNDALE MI
48220-0274
US

V. Phone/Fax

Practice location:
  • Phone: 248-629-0002
  • Fax: 248-808-6311
Mailing address:
  • Phone: 248-629-0002
  • Fax: 248-808-6311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number60142
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: