Provider Demographics
NPI:1467824763
Name:DUGAN, SAMANTHA (PSYD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:DUGAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:DUGAN-WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3600 S NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7311
Mailing Address - Country:US
Mailing Address - Phone:417-322-6622
Mailing Address - Fax:417-350-1935
Practice Address - Street 1:3600 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7311
Practice Address - Country:US
Practice Address - Phone:417-322-6622
Practice Address - Fax:417-350-1935
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015032102103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490026929Medicaid