Provider Demographics
NPI:1649032509
Name:WEDDERBURN, SAMANTHA JEAN (LMHC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JEAN
Last Name:WEDDERBURN
Suffix:
Gender:
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 BLUE HAW DR
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-5285
Mailing Address - Country:US
Mailing Address - Phone:516-242-5167
Mailing Address - Fax:
Practice Address - Street 1:233 BLUE HAW DR
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-5285
Practice Address - Country:US
Practice Address - Phone:516-366-1002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-26
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10014101YM0800X
NY014353101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health