Provider Demographics
NPI:1710245683
Name:WUNDERLICH, SAMANTHA R (CTRS, CBIS, CZT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:R
Last Name:WUNDERLICH
Suffix:
Gender:F
Credentials:CTRS, CBIS, CZT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20274
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-0274
Mailing Address - Country:US
Mailing Address - Phone:248-629-0002
Mailing Address - Fax:248-808-6311
Practice Address - Street 1:293 LEROY ST
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1890
Practice Address - Country:US
Practice Address - Phone:248-629-0002
Practice Address - Fax:248-808-6311
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI60142225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist