Provider Demographics
NPI:1780173948
Name:CASADONTE, SAMANTHA MARIE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:CASADONTE
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 1:1527 EDGEWOOD DR # MI
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1275
Mailing Address - Country:US
Mailing Address - Phone:248-331-6520
Mailing Address - Fax:
Practice Address - Street 1:5366 EASTERN AVE SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-6018
Practice Address - Country:US
Practice Address - Phone:616-608-3665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician