Provider Demographics
NPI:1568078004
Name:KIMMERER, SAMANTHA (BCABA, LABA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:KIMMERER
Suffix:
Gender:F
Credentials:BCABA, LABA
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:LOWERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1500 S DOUGLAS RD STE 230
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-4108
Mailing Address - Country:US
Mailing Address - Phone:844-244-1818
Mailing Address - Fax:
Practice Address - Street 1:2549 JOLLY RD STE 380
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3680
Practice Address - Country:US
Practice Address - Phone:989-217-8061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0-22-13745106E00000X
106S00000X
MI7402000149106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician