Provider Demographics
NPI:1629299953
Name:SAMUEL, MICHAL (MSW MA)
Entity Type:Individual
Prefix:MS
First Name:MICHAL
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:MSW MA
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:SAMUEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1524 DICKEN DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-4419
Mailing Address - Country:US
Mailing Address - Phone:734-926-9169
Mailing Address - Fax:734-348-9005
Practice Address - Street 1:1945 PAULINE BLVD STE 14
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-5047
Practice Address - Country:US
Practice Address - Phone:734-926-9169
Practice Address - Fax:734-348-9905
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI63010125831041C0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0960542OtherBLUE CROSS BLUE SHIELD
MI600074425OtherMAGELLAN
MI000986-4086OtherAETNA
453758OtherTRICARE
MIMI3251Medicare PIN