Provider Demographics
NPI:1295414126
Name:DEROSSETT, SAMUEL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:DEROSSETT
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 1:37681 SANDSTONE TRL
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:48048-3729
Mailing Address - Country:US
Mailing Address - Phone:618-319-0945
Mailing Address - Fax:
Practice Address - Street 1:37681 SANDSTONE TRL
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:MI
Practice Address - Zip Code:48048-3729
Practice Address - Country:US
Practice Address - Phone:618-319-0945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501012056225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist