MEDICARE: SAMANTHA SHOTARO

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1457065898
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA SHOTARO

Provider Business Mailing Address
First Line	:	4234 CASCADE RD SE STE 3
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-8384
Country	:	US
Telephone Number	:	888-614-4144
Fax Number	:	888-614-4144

Provider Business Practice Location Address
First Line	:	4234 CASCADE RD SE STE 3
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-8384
Country	:	US
Telephone Number	:	888-614-4144
Fax Number	:	888-614-4144

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

Provider Enumeration Date	:	01/10/2023
Last Update Date	:	04/20/2026

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Directions to “ SAMANTHA SHOTARO ” Practice Location

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