Provider Demographics
NPI:1326833849
Name:IRISH-LODGE, SAMSON MANOAH
Entity type:Individual
Prefix:
First Name:SAMSON
Middle Name:MANOAH
Last Name:IRISH-LODGE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10811 40TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-5422
Mailing Address - Country:US
Mailing Address - Phone:425-791-0989
Mailing Address - Fax:425-791-0989
Practice Address - Street 1:1237 W MAIN ST # 98272
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-2028
Practice Address - Country:US
Practice Address - Phone:425-405-0146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor