Provider Demographics
NPI:1245956929
Name:FLETCHER, SAMANTHA KELLY
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:KELLY
Last Name:FLETCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:KELLY
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:240 N TILLOTSON AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-3988
Mailing Address - Country:US
Mailing Address - Phone:765-288-1928
Mailing Address - Fax:765-741-0310
Practice Address - Street 1:240 N TILLOTSON AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-3988
Practice Address - Country:US
Practice Address - Phone:765-288-1928
Practice Address - Fax:765-741-0359
Is Sole Proprietor?:No
Enumeration Date:2022-10-14
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99114518A101Y00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor