Provider Demographics
NPI:1568144384
Name:WATSON, SAMANTHA MAILE LORENZO (MSW)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:MAILE LORENZO
Last Name:WATSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 LEGACY BLVD
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-5500
Mailing Address - Country:US
Mailing Address - Phone:808-227-1114
Mailing Address - Fax:
Practice Address - Street 1:460 LEGACY BLVD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-5500
Practice Address - Country:US
Practice Address - Phone:808-227-1114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAD23-043W101YA0400X
104100000X
HI3044-22101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)