Provider Demographics
NPI:1265003115
Name:ANDERSON, SAMSON WAYNE (CSW)
Entity type:Individual
Prefix:
First Name:SAMSON
Middle Name:WAYNE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7051 FREEDOM LN APT 203
Mailing Address - Street 2:
Mailing Address - City:SUMMERSET
Mailing Address - State:SD
Mailing Address - Zip Code:57718-8729
Mailing Address - Country:US
Mailing Address - Phone:606-620-2021
Mailing Address - Fax:
Practice Address - Street 1:350 ELK ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7351
Practice Address - Country:US
Practice Address - Phone:605-343-7262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25547104100000X
SD5252104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker