Provider Demographics
NPI:1093444226
Name:BEAHLEN, SAMANTHA JO (COTA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:BEAHLEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 CHESTNUT CIR W
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-9187
Mailing Address - Country:US
Mailing Address - Phone:810-835-9738
Mailing Address - Fax:
Practice Address - Street 1:1330 GRAND POINTE CT
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-5502
Practice Address - Country:US
Practice Address - Phone:810-695-8920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-04
Last Update Date:2022-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202009900224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant