Provider Demographics
NPI:1992291702
Name:TRIMBLE, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:TRIMBLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N PACIFIC COAST HWY STE 1400
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-5602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7375 WOODWARD AVE STE 2800
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3157
Practice Address - Country:US
Practice Address - Phone:313-251-6367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-04
Last Update Date:2024-08-19
Deactivation Date:2019-03-21
Deactivation Code:
Reactivation Date:2019-04-03
Provider Licenses
StateLicense IDTaxonomies
156F00000X, 247200000X
MI7401001455103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No156F00000XEye and Vision Services ProvidersTechnician/Technologist
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other