Healthcare Provider Details

I. General information

NPI: 1780397331
Provider Name (Legal Business Name): SAMANTHA VANSUMEREN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2022
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4285 DEVELOPMENT DR
LANSING MI
48911-4213
US

IV. Provider business mailing address

6009 STILLWATER LN
MIDLAND MI
48642-7037
US

V. Phone/Fax

Practice location:
  • Phone: 517-706-0421
  • Fax: 517-706-0423
Mailing address:
  • Phone: 989-615-5690
  • 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: