Provider Demographics
NPI:1942976980
Name:SAMSON, THERESA M
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:SAMSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 E MARISA PL
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-6685
Mailing Address - Country:US
Mailing Address - Phone:360-561-2002
Mailing Address - Fax:
Practice Address - Street 1:307 W COTA ST SHELTON WA 98584
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584
Practice Address - Country:US
Practice Address - Phone:360-205-8010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health