Provider Demographics
NPI:1962980888
Name:BROCKMEYER, SAMANTHA J (BA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:J
Last Name:BROCKMEYER
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:JO
Other - Last Name:BROCKMEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:11905 HASTINGS RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44125-4341
Mailing Address - Country:US
Mailing Address - Phone:440-453-0566
Mailing Address - Fax:
Practice Address - Street 1:525 AVON BELDEN RD STE 1
Practice Address - Street 2:
Practice Address - City:AVON LAKE
Practice Address - State:OH
Practice Address - Zip Code:44012-4101
Practice Address - Country:US
Practice Address - Phone:216-302-7805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-02
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.169590101YA0400X
171M00000X
OHS.20050431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator