Healthcare Provider Details

I. General information

NPI: 1912631789
Provider Name (Legal Business Name): SAMANTHA M VIDRINE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA R MCCARTNEY

II. Dates (important events)

Enumeration Date: 07/15/2022
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11990 JACKSON ST
CLINTON LA
70722-3210
US

IV. Provider business mailing address

PO BOX 395
CLINTON LA
70722-0395
US

V. Phone/Fax

Practice location:
  • Phone: 225-683-5292
  • Fax: 225-683-1310
Mailing address:
  • Phone: 225-683-5292
  • Fax: 225-683-1310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13378
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: