Provider Demographics
NPI:1306366273
Name:GILKERSON, SAMANTHA MARIE (PLMHP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:GILKERSON
Suffix:
Gender:F
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6291 KEITH RD
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:NE
Mailing Address - Zip Code:69301-5253
Mailing Address - Country:US
Mailing Address - Phone:308-760-5041
Mailing Address - Fax:308-217-4277
Practice Address - Street 1:815 FLACK AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:NE
Practice Address - Zip Code:69301-2722
Practice Address - Country:US
Practice Address - Phone:308-762-2723
Practice Address - Fax:308-217-4277
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-22
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11187101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE82-1936994Medicaid