Provider Demographics
NPI:1417420936
Name:COLE, SAMANTHA JEAN
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JEAN
Last Name:COLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8049 KENSINGTON BLVD APT 70
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-2294
Mailing Address - Country:US
Mailing Address - Phone:810-336-0736
Mailing Address - Fax:
Practice Address - Street 1:8049 KENSINGTON BLVD APT 70
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-2294
Practice Address - Country:US
Practice Address - Phone:810-336-0736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI007042420OtherBLUE CROSS BLUE SHIELD