Provider Demographics
NPI:1760171300
Name:MARK G SAMPSON PHD LLC
Entity Type:Organization
Organization Name:MARK G SAMPSON PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:734-255-8062
Mailing Address - Street 1:2786 E MORELAND DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43209-3066
Mailing Address - Country:US
Mailing Address - Phone:734-255-8062
Mailing Address - Fax:
Practice Address - Street 1:4041 N HIGH ST STE 300I
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3200
Practice Address - Country:US
Practice Address - Phone:614-683-5119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health