Provider Demographics
NPI:1932541810
Name:SAMSON, ZACHERY PAUL (PCSW 766)
Entity Type:Individual
Prefix:
First Name:ZACHERY
Middle Name:PAUL
Last Name:SAMSON
Suffix:
Gender:M
Credentials:PCSW 766
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 W PERSHING BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-2537
Mailing Address - Country:US
Mailing Address - Phone:801-657-1241
Mailing Address - Fax:
Practice Address - Street 1:821 W PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-2537
Practice Address - Country:US
Practice Address - Phone:801-657-1241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-22
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7661041C0700X
251C00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251C00000XAgenciesDay Training, Developmentally Disabled Services