1821685116 NPI number — MRS. SAMANTHA JESSICA INNISS LMSW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821685116 NPI number — MRS. SAMANTHA JESSICA INNISS LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
INNISS
Provider First Name:
SAMANTHA
Provider Middle Name:
JESSICA
Provider Name Prefix Text:
MRS.
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:
EDWARDS
Provider Other First Name:
SAMANTHA
Provider Other Middle Name:
JESSICA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1821685116
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18 BRIARWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINDSOR
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06095-4470
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-922-0060
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18 BRIARWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINDSOR
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06095-4470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-922-0060
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/21/2020

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: 1041C0700X , with the licence number:  13487 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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