Healthcare Provider Details

I. General information

NPI: 1285668509
Provider Name (Legal Business Name): SAMANTHA HARRISON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 1ST ST SW
ROANOKE VA
24016-4701
US

IV. Provider business mailing address

1115 1ST ST SW
ROANOKE VA
24016-4701
US

V. Phone/Fax

Practice location:
  • Phone: 540-343-0004
  • Fax: 540-343-1576
Mailing address:
  • Phone: 540-343-0004
  • Fax: 540-343-1576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904006009
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: