Healthcare Provider Details

I. General information

NPI: 1760173421
Provider Name (Legal Business Name): SAMANTHA ANNE DUFFEL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SAMANTHA ANNE RHINE LCSW

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SOUTHLAND DR
SIKESTON MO
63801-4403
US

IV. Provider business mailing address

6738 STATE HIGHWAY 77
BENTON MO
63736-8238
US

V. Phone/Fax

Practice location:
  • Phone: 573-472-1770
  • Fax: 573-472-4050
Mailing address:
  • Phone: 573-545-4200
  • Fax: 573-293-6841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2024000703
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: