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General NPI Number Information
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NPI Number | 1356878128
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Entity Type | Organization
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Legal Business Name | SAMANTHA L CHARBONNEAU PA
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Dates
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Enumeration Date | 05/11/2017
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Last Update Date | 05/11/2017
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Provider Practice Location Address
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Address Line | 101 TIMBERLACHEN CIR STE 201
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City | LAKE MARY
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State | FL
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Zip | 32746-6124
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Country | US
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Telephone | 407-466-3467
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Fax | 407-549-5987
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Provider Business Mailing Address
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Address Line | 101 TIMBERLACHEN CIR STE 201
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City | LAKE MARY
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State | FL
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Zip | 32746-6124
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Country | US
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Telephone | 407-466-3467
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Fax | 407-549-5987
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Authorized Official
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Title or Position | MARRIAGE AND FAMILY THERAPIST
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Name | MRS. SAMANTHA LYNN CHARBONNEAU
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Credential | LMFT
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Telephone | 407-466-3467
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MT2058
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License Number State | FL
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