Provider Demographics
NPI:1801284849
Name:VON DER HEYDT, SAMANTHA (LIC AC, MAC)
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:
Last Name:VON DER HEYDT
Suffix:
Gender:F
Credentials:LIC AC, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WHITE SULPHER SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:24986-2212
Mailing Address - Country:US
Mailing Address - Phone:304-536-5074
Mailing Address - Fax:304-536-5112
Practice Address - Street 1:100 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:WHITE SULPHER SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:24986-2212
Practice Address - Country:US
Practice Address - Phone:304-536-5074
Practice Address - Fax:304-536-5112
Is Sole Proprietor?:No
Enumeration Date:2014-12-29
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV96158171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist