Provider Demographics
NPI:1235888082
Name:KINKOPF, SAMANTHA ROSE (MA, LHMC (MH 20499))
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:ROSE
Last Name:KINKOPF
Suffix:
Gender:F
Credentials:MA, LHMC (MH 20499)
Other - Prefix:MISS
Other - First Name:SAMANTHA
Other - Middle Name:ROSE
Other - Last Name:SHAFFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1909 S OAK AVE
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-3854
Mailing Address - Country:US
Mailing Address - Phone:407-462-5349
Mailing Address - Fax:
Practice Address - Street 1:1909 S OAK AVE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-3854
Practice Address - Country:US
Practice Address - Phone:407-462-5349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20499101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health