Provider Demographics
NPI:1871135533
Name:SUMMERS, SAMANTHA RENAE (CHW)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RENAE
Last Name:SUMMERS
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 N 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-1311
Mailing Address - Country:US
Mailing Address - Phone:503-302-2459
Mailing Address - Fax:
Practice Address - Street 1:1401 N 10TH AVE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-1311
Practice Address - Country:US
Practice Address - Phone:503-302-2459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
ORTHW000110507172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician