Healthcare Provider Details

I. General information

NPI: 1194372607
Provider Name (Legal Business Name): SAMANTHA LEMMER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2019
Last Update Date: 08/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2566 WOODMEADOW DR SE
GRAND RAPIDS MI
49546-8031
US

IV. Provider business mailing address

19477 47TH ST
BLOOMINGDALE MI
49026-9787
US

V. Phone/Fax

Practice location:
  • Phone: 616-719-0194
  • Fax:
Mailing address:
  • Phone: 312-961-7609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401017560
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: