Provider Demographics
NPI:1255944096
Name:SAMSON, ERIC S
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:S
Last Name:SAMSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6506 HERITAGE
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-1340
Mailing Address - Country:US
Mailing Address - Phone:248-907-5677
Mailing Address - Fax:
Practice Address - Street 1:2045 E WEST MAPLE RD STE D405
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48390-3801
Practice Address - Country:US
Practice Address - Phone:248-669-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-30
Last Update Date:2020-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009092103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist