Provider Demographics
NPI:1851803696
Name:MOOG, SAMANTHA L (LCSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:L
Last Name:MOOG
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 1:807 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-4541
Mailing Address - Country:US
Mailing Address - Phone:484-888-5359
Mailing Address - Fax:
Practice Address - Street 1:807 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-4541
Practice Address - Country:US
Practice Address - Phone:484-888-5359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-02
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200061111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical