Provider Demographics
NPI:1962808782
Name:SAMKOWIAK, HEATHER A
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:A
Last Name:SAMKOWIAK
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:DAUGHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1941 OPAL LAKE RD
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-7651
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 RIVER ST
Practice Address - Street 2:
Practice Address - City:BOYNE CITY
Practice Address - State:MI
Practice Address - Zip Code:49712-1234
Practice Address - Country:US
Practice Address - Phone:989-370-4225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013702101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor