Provider Demographics
NPI:1811543119
Name:DITTRICH, SAMANTHA MARIE (LCSW)
Entity Type:Individual
Prefix:MISS
First Name:SAMANTHA
Middle Name:MARIE
Last Name:DITTRICH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02364-2197
Mailing Address - Country:US
Mailing Address - Phone:781-812-6302
Mailing Address - Fax:
Practice Address - Street 1:169 LIBBEY PKWY
Practice Address - Street 2:
Practice Address - City:WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02189-3189
Practice Address - Country:US
Practice Address - Phone:781-474-5287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2280211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA228021OtherBOARD OF SOCIAL WORKERS