Healthcare Provider Details

I. General information

NPI: 1801328489
Provider Name (Legal Business Name): SAMANTHA REITSMA M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2017
Last Update Date: 04/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3260 EAGLE PARK DR NE SUITE 117
GRAND RAPIDS MI
49525-4569
US

IV. Provider business mailing address

1291 PARNELL AVE SE
ADA MI
49301-8903
US

V. Phone/Fax

Practice location:
  • Phone: 616-530-2224
  • Fax: 616-825-6164
Mailing address:
  • Phone: 616-401-7225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101005216
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: