Provider Demographics
NPI:1467441980
Name:LAWLESS, SAM (MSW)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:LAWLESS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 US HIGHWAY 1 S
Mailing Address - Street 2:SUITE C-2
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-3708
Mailing Address - Country:US
Mailing Address - Phone:904-209-6001
Mailing Address - Fax:904-209-6002
Practice Address - Street 1:1955 US HIGHWAY 1 S
Practice Address - Street 2:SUITE C-2
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3708
Practice Address - Country:US
Practice Address - Phone:904-209-6001
Practice Address - Fax:904-209-6002
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW91291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL757217400Medicaid
FLBE751ZMedicare PIN