Healthcare Provider Details

I. General information

NPI: 1013867258
Provider Name (Legal Business Name): LEEYAH SAMUELS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2026
Last Update Date: 02/11/2026
Certification Date: 02/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 3 MILE RD NW STE 200
GRAND RAPIDS MI
49544-1691
US

IV. Provider business mailing address

11088 52ND AVE APT 10
ALLENDALE MI
49401-9286
US

V. Phone/Fax

Practice location:
  • Phone: 616-469-3870
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: