Provider Demographics
NPI:1770791931
Name:FARGEON, SAMANTHA (LCSW)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:FARGEON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 EL DORADO AVE APT 206
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5075
Mailing Address - Country:US
Mailing Address - Phone:510-326-1573
Mailing Address - Fax:
Practice Address - Street 1:501 VIA CASITAS
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-1993
Practice Address - Country:US
Practice Address - Phone:415-464-1722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA820311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical