Basic Information
| Provider Information | |||||||||
| NPI: | 1639687759 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMUEL | ||||||||
| FirstName: | BRANDIE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| NameSuffix: | |||||||||
| Credential: | LLPC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 128 S COCHRAN AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488131510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173259090 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 128 S COCHRAN AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488131510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173259090 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2018 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 05/27/2020 | ||||||||
| NPIReactivationDate: | 01/22/2021 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6401016251 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.