Provider Demographics
NPI:1912541871
Name:MOEAI, SAMANTHA (LCSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MOEAI
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 1:4465 S 900 E STE 150
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3944
Mailing Address - Country:US
Mailing Address - Phone:801-472-8382
Mailing Address - Fax:510-480-1207
Practice Address - Street 1:1881 N 1120 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1180
Practice Address - Country:US
Practice Address - Phone:801-472-8382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT98831513501101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health