1740899285 NPI number — SAMANTHA MARIE PRUST MSW, LCSW

Table of content: SAMANTHA MARIE PRUST MSW, LCSW (NPI 1740899285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740899285 NPI number — SAMANTHA MARIE PRUST MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRUST
Provider First Name:
SAMANTHA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW
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:
1740899285
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
323 S 18TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STURGEON BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54235-1401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2345 CANTERBURY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SISTER BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54234-5602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-868-3511
Provider Business Practice Location Address Fax Number:
608-270-0467
Provider Enumeration Date:
07/30/2020

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:  131979-121 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 11314-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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