Healthcare Provider Details

I. General information

NPI: 1477666964
Provider Name (Legal Business Name): MRS. SAMMIE M MATTHEWS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 10/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 10 AVE
PORT HURON MI
48060-3822
US

IV. Provider business mailing address

2903 NORTH BLVD
PORT HURON MI
48060-6986
US

V. Phone/Fax

Practice location:
  • Phone: 810-982-3042
  • Fax: 810-982-3042
Mailing address:
  • Phone: 810-650-1515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: