Provider Demographics
NPI:1750407110
Name:SAMPSON, LIZA M (BS)
Entity type:Individual
Prefix:
First Name:LIZA
Middle Name:M
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51A SEATON VALLEY PATH
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-5364
Mailing Address - Country:US
Mailing Address - Phone:386-236-1812
Mailing Address - Fax:
Practice Address - Street 1:1150 RED JOHN DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32124-1016
Practice Address - Country:US
Practice Address - Phone:386-236-1770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health