Provider Demographics
NPI:1366021727
Name:DITTO, SAMANTHA JILL (LMSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JILL
Last Name:DITTO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 299
Mailing Address - Street 2:
Mailing Address - City:HOXIE
Mailing Address - State:AR
Mailing Address - Zip Code:72433-0299
Mailing Address - Country:US
Mailing Address - Phone:870-886-1333
Mailing Address - Fax:
Practice Address - Street 1:503 SE LINDSEY ST
Practice Address - Street 2:
Practice Address - City:HOXIE
Practice Address - State:AR
Practice Address - Zip Code:72433-2224
Practice Address - Country:US
Practice Address - Phone:870-886-1333
Practice Address - Fax:870-886-1334
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR10215-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR265815795Medicaid