Provider Demographics
NPI:1063860955
Name:BRENEMAN, SAMANTHA RAE (LLP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RAE
Last Name:BRENEMAN
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 GRAND RIVER RD STE 290
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-7340
Mailing Address - Country:US
Mailing Address - Phone:810-220-2787
Mailing Address - Fax:810-220-2834
Practice Address - Street 1:7600 GRAND RIVER RD STE 290
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-7340
Practice Address - Country:US
Practice Address - Phone:810-220-2787
Practice Address - Fax:810-220-2834
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2020-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301018378103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical