Provider Demographics
NPI:1164004636
Name:TWIDLE, SAMANTHA P (LSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:P
Last Name:TWIDLE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 STOCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:OCEAN GROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:07756-1044
Mailing Address - Country:US
Mailing Address - Phone:732-275-4878
Mailing Address - Fax:
Practice Address - Street 1:149 AVENUE AT THE CMN STE 4
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702-4583
Practice Address - Country:US
Practice Address - Phone:609-388-8701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-24
Last Update Date:2021-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06582200104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty