Provider Demographics
NPI:1821476938
Name:SAMUELSSON, DEIRDRE KENNEDY (LICSW)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:KENNEDY
Last Name:SAMUELSSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 CLIFTON AVE
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-1737
Mailing Address - Country:US
Mailing Address - Phone:781-631-8273
Mailing Address - Fax:
Practice Address - Street 1:66 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945-1737
Practice Address - Country:US
Practice Address - Phone:781-631-8273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALICSW1114601041C0700X
CALCS293851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical