1356878128 NPI number — SAMANTHA L CHARBONNEAU PA

Table of content: (NPI 1356878128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356878128 NPI number — SAMANTHA L CHARBONNEAU PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAMANTHA L CHARBONNEAU PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356878128
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 TIMBERLACHEN CIR STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE MARY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32746-6124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-466-3467
Provider Business Mailing Address Fax Number:
407-549-5987

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 TIMBERLACHEN CIR STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE MARY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32746-6124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-466-3467
Provider Business Practice Location Address Fax Number:
407-549-5987
Provider Enumeration Date:
05/11/2017

Additional Information

Authorized Official

Authorized Official Last Name:
CHARBONNEAU
Authorized Official First Name:
SAMANTHA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
MARRIAGE AND FAMILY THERAPIST
Authorized Official Telephone Number:
407-466-3467

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  MT2058 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1982634275 . This is a "NPI TYPE 1" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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