Provider Demographics
NPI:1396915542
Name:LEE, SAMANTHA GWEN (LMSW, LASAC)
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:GWEN
Last Name:LEE
Suffix:
Gender:F
Credentials:LMSW, LASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 589
Mailing Address - Street 2:
Mailing Address - City:FORT DEFIANCE
Mailing Address - State:AZ
Mailing Address - Zip Code:86504-0589
Mailing Address - Country:US
Mailing Address - Phone:928-729-8500
Mailing Address - Fax:928-729-8000
Practice Address - Street 1:CORNER OF ROUTE N12 AND N7
Practice Address - Street 2:
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13084101Y00000X
AZ11643104100000X
AZ160481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker