Provider Demographics
NPI:1598471955
Name:VERMILLION, SAMANTHA (COTA/L)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:VERMILLION
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29322 ROSEBRIAR ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3038
Mailing Address - Country:US
Mailing Address - Phone:586-524-7153
Mailing Address - Fax:
Practice Address - Street 1:29800 HOOVER RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-8918
Practice Address - Country:US
Practice Address - Phone:586-574-3444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202007943224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant