Provider Demographics
NPI:1609363480
Name:PUSH, SAMANTHA JO (LMSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:PUSH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:JO
Other - Last Name:SGROI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2279 MARK AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-2550
Mailing Address - Country:US
Mailing Address - Phone:810-941-7904
Mailing Address - Fax:
Practice Address - Street 1:79 W ALEXANDRINE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2015
Practice Address - Country:US
Practice Address - Phone:313-831-5535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011150841041C0700X
MI68011020051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical