Provider Demographics
NPI:1083294698
Name:KOVATCH, SAMANTHA M (LCSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:M
Last Name:KOVATCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 N 62ND ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-4170
Mailing Address - Country:US
Mailing Address - Phone:920-207-9566
Mailing Address - Fax:
Practice Address - Street 1:1300 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-2602
Practice Address - Country:US
Practice Address - Phone:414-467-1548
Practice Address - Fax:414-225-1346
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9677-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical