MEDICARE: SAMANTHA MARIE FULLER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1063361574
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA MARIE FULLER

Provider Business Mailing Address
First Line	:	4407 CLAYBORNE DR APT 301
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49009-2751
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4407 CLAYBORNE DR APT 301
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49009-2751
Country	:	US
Telephone Number	:	269-373-6000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2026
Last Update Date	:	01/27/2026

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Directions to “ SAMANTHA MARIE FULLER ” Practice Location

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