Provider Demographics
NPI:1336448729
Name:RUNCO, SAMANTHA MICHELLE (LSW, MED)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:MICHELLE
Last Name:RUNCO
Suffix:
Gender:F
Credentials:LSW, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 KENNEBEC RD
Mailing Address - Street 2:
Mailing Address - City:HAMPDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04444-1318
Mailing Address - Country:US
Mailing Address - Phone:207-862-3256
Mailing Address - Fax:
Practice Address - Street 1:24 MORTLAND RD
Practice Address - Street 2:
Practice Address - City:SEARSPORT
Practice Address - State:ME
Practice Address - Zip Code:04974-6311
Practice Address - Country:US
Practice Address - Phone:207-548-2311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELS82991041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool