Provider Demographics
NPI:1497069488
Name:SLACK, SAMANTHA MICHELLE (LMSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MICHELLE
Last Name:SLACK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:LANGSTAFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1440 TORREY RD STE E
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-1340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1440 TORREY RD STE E
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430
Practice Address - Country:US
Practice Address - Phone:999-999-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010939731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical