1770176240 NPI number — SAMANTHA LORAINE BLANCO MSW, BSW, LCSW

Table of content: SAMANTHA LORAINE BLANCO MSW, BSW, LCSW (NPI 1770176240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770176240 NPI number — SAMANTHA LORAINE BLANCO MSW, BSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLANCO
Provider First Name:
SAMANTHA
Provider Middle Name:
LORAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, BSW, LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BAPTISTE
Provider Other First Name:
SAMANTHA
Provider Other Middle Name:
LORAINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW, BSW, LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770176240
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 SUNNYBROOK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27610-1808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-580-0594
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
220 SWINBURNE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27610-1834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-212-7000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/16/2021

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: 1041C0700X , with the licence number:  P014362 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: C014851 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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