Provider Demographics
NPI:1528889193
Name:LARSON, SAMANTHA JO
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JO
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:JO
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1110 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:MENOMINEE
Mailing Address - State:MI
Mailing Address - Zip Code:49858-3058
Mailing Address - Country:US
Mailing Address - Phone:906-290-5000
Mailing Address - Fax:906-863-2408
Practice Address - Street 1:1110 10TH AVE
Practice Address - Street 2:
Practice Address - City:MENOMINEE
Practice Address - State:MI
Practice Address - Zip Code:49858-3058
Practice Address - Country:US
Practice Address - Phone:906-290-5000
Practice Address - Fax:906-863-2408
Is Sole Proprietor?:No
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator