Healthcare Provider Details

I. General information

NPI: 1225783277
Provider Name (Legal Business Name): SAMANTHA MARIE SHIELDS LGSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2022
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4540 US ROUTE 60
HUNTINGTON WV
25705-1936
US

IV. Provider business mailing address

4540 US ROUTE 60
HUNTINGTON WV
25705-1936
US

V. Phone/Fax

Practice location:
  • Phone: 304-525-7111
  • Fax: 304-525-7112
Mailing address:
  • Phone: 304-525-7111
  • Fax: 304-525-7112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberBP00946033
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: