Provider Demographics
NPI:1699443317
Name:MACKSON, SAMANTHA BRYN (PSYD)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:BRYN
Last Name:MACKSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 E PALMETTO PARK RD APT 443
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-5185
Mailing Address - Country:US
Mailing Address - Phone:954-600-5405
Mailing Address - Fax:
Practice Address - Street 1:10205 S DIXIE HWY STE 203
Practice Address - Street 2:
Practice Address - City:PINECREST
Practice Address - State:FL
Practice Address - Zip Code:33156-3168
Practice Address - Country:US
Practice Address - Phone:305-662-2686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY11220103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist