Healthcare Provider Details

I. General information

NPI: 1053124248
Provider Name (Legal Business Name): SAMANTHA A HARRIS MSW, LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2025
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4066 DUNNICA AVE
SAINT LOUIS MO
63116-3510
US

IV. Provider business mailing address

900 E LAHARPE ST
KIRKSVILLE MO
63501-4520
US

V. Phone/Fax

Practice location:
  • Phone: 636-224-1700
  • Fax:
Mailing address:
  • Phone: 636-224-1210
  • Fax: 636-946-1008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2025002141
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: