Provider Demographics
NPI:1639687759
Name:SAMUEL, BRANDIE NICOLE (LLPC)
Entity Type:Individual
Prefix:
First Name:BRANDIE
Middle Name:NICOLE
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 S COCHRAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813-1510
Mailing Address - Country:US
Mailing Address - Phone:517-325-9090
Mailing Address - Fax:
Practice Address - Street 1:128 S COCHRAN AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1510
Practice Address - Country:US
Practice Address - Phone:517-325-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2021-12-09
Deactivation Date:2020-05-27
Deactivation Code:
Reactivation Date:2021-01-22
Provider Licenses
StateLicense IDTaxonomies
MI6401016251101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health