Provider Demographics
NPI:1669021457
Name:DEVINE, SAMANTHA JO (MA, LMFT)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:DEVINE
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:JO
Other - Last Name:FOREHAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5 PREMIER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2943
Mailing Address - Country:US
Mailing Address - Phone:314-544-3800
Mailing Address - Fax:
Practice Address - Street 1:5 PREMIER DR STE 200
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2943
Practice Address - Country:US
Practice Address - Phone:314-544-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017026551106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist