Provider Demographics
NPI:1356878128
Name:SAMANTHA L CHARBONNEAU PA
Entity type:Organization
Organization Name:SAMANTHA L CHARBONNEAU PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MARRIAGE AND FAMILY THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CHARBONNEAU
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:407-466-3467
Mailing Address - Street 1:101 TIMBERLACHEN CIR STE 201
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-6124
Mailing Address - Country:US
Mailing Address - Phone:407-466-3467
Mailing Address - Fax:407-549-5987
Practice Address - Street 1:101 TIMBERLACHEN CIR STE 201
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-6124
Practice Address - Country:US
Practice Address - Phone:407-466-3467
Practice Address - Fax:407-549-5987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT2058106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1982634275OtherNPI TYPE 1