MEDICARE: SAMANTHA L KLOKKERT MSW INTERN

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1336781939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA L KLOKKERT MSW INTERN

Provider Business Mailing Address
First Line	:	2013 EASTCASTLE DR SE STE B
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-8873
Country	:	US
Telephone Number	:	616-888-1120
Fax Number	:

Provider Business Practice Location Address
First Line	:	2013 EASTCASTLE DR SE STE B
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-8873
Country	:	US
Telephone Number	:	616-888-1120
Fax Number	:

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

Provider Enumeration Date	:	10/15/2019
Last Update Date	:	10/15/2019

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