Provider Demographics
NPI:1396337275
Name:MALL, SAMANTHA ANNE (LLMSW)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANNE
Last Name:MALL
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3751 NORTH DIXIE HIGHWAY MONROE
Mailing Address - Street 2:
Mailing Address - City:MONORE
Mailing Address - State:MI
Mailing Address - Zip Code:48162
Mailing Address - Country:US
Mailing Address - Phone:574-226-5895
Mailing Address - Fax:
Practice Address - Street 1:19401 NORTHLINE RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2277
Practice Address - Country:US
Practice Address - Phone:734-785-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-11
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZI1000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherIllustration, Medical