Provider Demographics
NPI:1073173969
Name:GILBERTSON, SAMANTHA MARIE (CDPT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARIE
Last Name:GILBERTSON
Suffix:
Gender:F
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18945 PRAIRIE ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:WA
Mailing Address - Zip Code:98579-9232
Mailing Address - Country:US
Mailing Address - Phone:360-529-9711
Mailing Address - Fax:
Practice Address - Street 1:200 LILLY RD NE STE C
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5080
Practice Address - Country:US
Practice Address - Phone:360-918-8336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60950585101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)