Provider Demographics
NPI:1164068128
Name:BLACKADAR, SAMANTHA (LCSW, LICSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BLACKADAR
Suffix:
Gender:F
Credentials:LCSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 EVANS ROAD
Mailing Address - Street 2:
Mailing Address - City:BRIDGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04009
Mailing Address - Country:US
Mailing Address - Phone:603-969-5317
Mailing Address - Fax:
Practice Address - Street 1:100 GANNETT DR
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-5900
Practice Address - Country:US
Practice Address - Phone:207-854-1030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LC183851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical