Healthcare Provider Details

I. General information

NPI: 1972327930
Provider Name (Legal Business Name): SAMANTHA STAFFORD MA, LLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13305 REECK CT
SOUTHGATE MI
48195-3197
US

IV. Provider business mailing address

26545 AMERICAN DR
SOUTHFIELD MI
48034-6115
US

V. Phone/Fax

Practice location:
  • Phone: 800-395-3223
  • Fax:
Mailing address:
  • Phone: 800-395-3223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451024373
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: