Provider Demographics
NPI:1821685116
Name:INNISS, SAMANTHA JESSICA (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:JESSICA
Last Name:INNISS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:JESSICA
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:18 BRIARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-4470
Mailing Address - Country:US
Mailing Address - Phone:860-922-0060
Mailing Address - Fax:
Practice Address - Street 1:18 BRIARWOOD DR
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-4470
Practice Address - Country:US
Practice Address - Phone:860-922-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT134871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical