Provider Demographics
NPI:1417463183
Name:BERGSTEIN, SAMANTHA LEE (LISW-S)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEE
Last Name:BERGSTEIN
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4041 N HIGH ST STE 300H
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-3200
Mailing Address - Country:US
Mailing Address - Phone:614-984-4394
Mailing Address - Fax:614-319-5618
Practice Address - Street 1:4041 N HIGH ST STE 300H
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3200
Practice Address - Country:US
Practice Address - Phone:614-984-4394
Practice Address - Fax:614-319-5618
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-18
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1700637104100000X
OHI.19019391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0413879Medicaid
OH0264054Medicaid