Provider Demographics
NPI:1730810029
Name:BEATON, SAMANTHA JANE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JANE
Last Name:BEATON
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 1:316 S FULTON ST
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-1552
Mailing Address - Country:US
Mailing Address - Phone:419-902-2490
Mailing Address - Fax:
Practice Address - Street 1:6530 SECOR RD STE 6
Practice Address - Street 2:
Practice Address - City:LAMBERTVILLE
Practice Address - State:MI
Practice Address - Zip Code:48144-9456
Practice Address - Country:US
Practice Address - Phone:313-395-3072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-18
Last Update Date:2022-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511149631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical