MEDICARE: SAMOEUTROEUTTEANA MAO BECKETT LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	123003	MA
2	1041C0700X	Clinical Social Worker	10235-123	WI
3	1041C0700X	Clinical Social Worker	4545	HI

General Provider Information

NPI Number	:	1568982478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMOEUTROEUTTEANA MAO BECKETT LCSW

Provider Business Mailing Address
First Line	:	777 N JEFFERSON ST STE 408
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-3713
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1433 N WATER ST FL 4
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-2557
Country	:	US
Telephone Number	:	646-941-7645
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2017
Last Update Date	:	10/29/2024

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