1043519077 NPI number — SAMANTHA JOY UNDERWOOD LMSW

Table of content: SAMANTHA JOY UNDERWOOD LMSW (NPI 1043519077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043519077 NPI number — SAMANTHA JOY UNDERWOOD LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
UNDERWOOD
Provider First Name:
SAMANTHA
Provider Middle Name:
JOY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043519077
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12425 W 120TH ST
Provider Second Line Business Mailing Address:
APT. 1022
Provider Business Mailing Address City Name:
OVERLAND PARK
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66213-4838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-702-4077
Provider Business Mailing Address Fax Number:
913-894-0908

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12351 W 96TH TER
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
LENEXA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66215-4409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-894-0900
Provider Business Practice Location Address Fax Number:
913-894-8908
Provider Enumeration Date:
03/16/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  7557 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 23-7368880 , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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