Provider Demographics
NPI:1023314796
Name:NILSSON, SAMANTHA LYNNE (LCSW)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LYNNE
Last Name:NILSSON
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 1:130 RICHARDSON DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-2124
Mailing Address - Country:US
Mailing Address - Phone:860-357-1734
Mailing Address - Fax:
Practice Address - Street 1:51 N ELM ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-1545
Practice Address - Country:US
Practice Address - Phone:203-574-4000
Practice Address - Fax:203-574-4003
Is Sole Proprietor?:No
Enumeration Date:2011-01-28
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT172V00000X
101YM0800X
CT0087031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008057448Medicaid