Provider Demographics
NPI:1386183267
Name:DENTON, SAMUEL L (LCSW)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:L
Last Name:DENTON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6392 LINDEN RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61109-2816
Mailing Address - Country:US
Mailing Address - Phone:779-368-0060
Mailing Address - Fax:779-368-0579
Practice Address - Street 1:6392 LINDEN RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61109-2816
Practice Address - Country:US
Practice Address - Phone:779-368-0060
Practice Address - Fax:779-368-0579
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490167621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical