Healthcare Provider Details

I. General information

NPI: 1225149032
Provider Name (Legal Business Name): GARY MICHAEL SAMPSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 11TH AVENUE
LONGVIEW WA
98632
US

IV. Provider business mailing address

945 11TH AVENUE
LONGVIEW WA
98632
US

V. Phone/Fax

Practice location:
  • Phone: 888-313-8600
  • Fax: 360-636-7372
Mailing address:
  • Phone: 888-313-8600
  • Fax: 360-636-7372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1269
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: