| Doctor Name: | MR. PAUL TIMOTHY SAMUELSON |
| NPI Number: | 1134442502 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LLPC |
| License Number: | 6401009994 |
| Business Practice Address: | 601 E Washington St Suite A Ionia, MI - 488461871 |
| Business Phone Number: | 6165220836 |
| Business Fax Number: | 6165220841 |
| Mailing Address: | 40 Jefferson Ave . Se, Catholic Charities West Mi GRAND RAPIDS |
| State: | MI |
| Postal Code: | 49503 |
| Phone Number: | 6164561443 |
| Fax Number: | 6169889738 |
| NPI Enumeration Date: | 03/12/2010 |
| NPI Last Update Date: | 03/12/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | 6401009994 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |