Provider Demographics
NPI:1114491693
Name:BUCHANAN-NORTHUP, SAMANTHA JO (MSTCM LAC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:BUCHANAN-NORTHUP
Suffix:
Gender:F
Credentials:MSTCM LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17770 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48230
Mailing Address - Country:US
Mailing Address - Phone:313-924-5514
Mailing Address - Fax:
Practice Address - Street 1:17770 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230
Practice Address - Country:US
Practice Address - Phone:313-924-5514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17303171100000X
MI5402000031171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17303Medicaid