Provider Demographics
NPI:1285668509
Name:HARRISON, SAMANTHA (LCSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:HARRISON
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 1:1115 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4701
Mailing Address - Country:US
Mailing Address - Phone:540-343-0004
Mailing Address - Fax:540-343-1576
Practice Address - Street 1:1115 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4701
Practice Address - Country:US
Practice Address - Phone:540-343-0004
Practice Address - Fax:540-343-1576
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040060091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA177965OtherANTHEM
VA008139M68Medicare ID - Type Unspecified