MEDICARE: SAMANTHA ANN NELSON

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	101YM0800X	Mental Health Counselor	4101006817	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4101006817	OTHER	MI	LLMFT

General Provider Information

NPI Number	:	1518424936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA ANN NELSON

Provider Business Mailing Address
First Line	:	9414 FULMER RD
Second Line	:
City	:	MILLINGTON
State	:	MI
Zip	:	48746-9703
Country	:	US
Telephone Number	:	810-610-9277
Fax Number	:

Provider Business Practice Location Address
First Line	:	6598 BRUSH ST
Second Line	:
City	:	NORTH BRANCH
State	:	MI
Zip	:	48461-8842
Country	:	US
Telephone Number	:	810-610-9277
Fax Number	:

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

Provider Enumeration Date	:	02/21/2019
Last Update Date	:	02/21/2019

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Directions to “ SAMANTHA ANN NELSON ” Practice Location

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