Provider Demographics
NPI:1134156433
Name:MJENZI, SAMANTHA (LCSW)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MJENZI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:290 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-2667
Mailing Address - Country:US
Mailing Address - Phone:413-210-4785
Mailing Address - Fax:
Practice Address - Street 1:47 PALOMBA DR
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3868
Practice Address - Country:US
Practice Address - Phone:860-253-5020
Practice Address - Fax:860-253-5030
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC00520Medicare ID - Type UnspecifiedFACILITY MEDICARE NUMBER