Healthcare Provider Details

I. General information

NPI: 1346173895
Provider Name (Legal Business Name): SAMANTHA SIMON COUNSELING, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 VAN BUREN ST
SOUTH HAVEN MI
49090-1236
US

IV. Provider business mailing address

109 VAN BUREN ST
SOUTH HAVEN MI
49090-1236
US

V. Phone/Fax

Practice location:
  • Phone: 269-779-1023
  • Fax:
Mailing address:
  • Phone: 269-779-1023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SAMANTHA ANN SIMON
Title or Position: LIMITED LICENSED PSYCHOLOGIST
Credential: MA LLP
Phone: 269-779-1023