Provider Demographics
NPI:1003331182
Name:HALE, SAMANTHA BLAIR (MED, PCMHT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:BLAIR
Last Name:HALE
Suffix:
Gender:F
Credentials:MED, PCMHT
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:BLAIR
Other - Last Name:WITCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED,PCMHT
Mailing Address - Street 1:PO BOX 701
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39060-0701
Mailing Address - Country:US
Mailing Address - Phone:601-473-2106
Mailing Address - Fax:601-473-2150
Practice Address - Street 1:604 HIGHWAY 80 W STE R
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056
Practice Address - Country:US
Practice Address - Phone:601-473-2106
Practice Address - Fax:601-473-2150
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-09
Last Update Date:2019-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)