Provider Demographics
NPI:1932711165
Name:AVERETT, SAMANTHA PAIGE (LMSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:PAIGE
Last Name:AVERETT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:PAIGE
Other - Last Name:AVERETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1472
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221
Mailing Address - Country:US
Mailing Address - Phone:208-782-3434
Mailing Address - Fax:208-782-1389
Practice Address - Street 1:60 N BROADWAY
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221
Practice Address - Country:US
Practice Address - Phone:208-782-3434
Practice Address - Fax:208-782-1389
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker