Provider Demographics
NPI:1134887250
Name:WILSON, SAMANTHA RYAN (LMHC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RYAN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:RYAN
Other - Last Name:ROACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1615 SW MARIPOSA DR
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:FL
Mailing Address - Zip Code:34266-8545
Mailing Address - Country:US
Mailing Address - Phone:815-761-5454
Mailing Address - Fax:
Practice Address - Street 1:24451 SANDHILL BLVD UNIT B
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33983-5214
Practice Address - Country:US
Practice Address - Phone:941-347-8447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH18559101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health