Provider Demographics
NPI:1336689314
Name:LARSON, SAMANTHA N (LCSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:N
Last Name:LARSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:N
Other - Last Name:RASHID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:444 N WESTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-5715
Mailing Address - Country:US
Mailing Address - Phone:920-750-7000
Mailing Address - Fax:920-364-2451
Practice Address - Street 1:442 N WESTHILL BLVD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-5715
Practice Address - Country:US
Practice Address - Phone:920-750-7000
Practice Address - Fax:920-364-2451
Is Sole Proprietor?:No
Enumeration Date:2017-02-24
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9003104100000X
WI130252-121104100000X
WI9003-123104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100064946Medicaid
WI100064946Medicaid