Healthcare Provider Details

I. General information

NPI: 1538719661
Provider Name (Legal Business Name): SAMANTHA STREET LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 BEDFORD ST
FALL RIVER MA
02720-3050
US

IV. Provider business mailing address

110 RUSS ST
RANDOLPH MA
02368-1739
US

V. Phone/Fax

Practice location:
  • Phone: 650-388-0831
  • Fax:
Mailing address:
  • Phone: 650-388-0831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number225242
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: