Provider Demographics
NPI:1770168494
Name:KIRK, SAMANTHA DARLENE
Entity type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:DARLENE
Last Name:KIRK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 443
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48811-0443
Mailing Address - Country:US
Mailing Address - Phone:989-493-7525
Mailing Address - Fax:
Practice Address - Street 1:623 W WARWICK DR
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1177
Practice Address - Country:US
Practice Address - Phone:989-285-1490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician