Provider Demographics
NPI:1174254445
Name:NELSON-ZIRZOW, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:NELSON-ZIRZOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3828 NAGAWICKA SHORES DR
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-8819
Mailing Address - Country:US
Mailing Address - Phone:262-391-0658
Mailing Address - Fax:
Practice Address - Street 1:3828 NAGAWICKA SHORES DR
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-8819
Practice Address - Country:US
Practice Address - Phone:262-391-0658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-18
Last Update Date:2022-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000000OtherYOSAT