Basic Information
Provider Information | |||||||||
NPI: | 1205266236 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FITZPATRICK | ||||||||
FirstName: | SAMANTHA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | SW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 300 | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | PA | ||||||||
PostalCode: | 170420300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7172707780 | ||||||||
FaxNumber: | 7172749746 | ||||||||
Practice Location | |||||||||
Address1: | 30 N 4TH ST | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | LEBANON | ||||||||
State: | PA | ||||||||
PostalCode: | 170465606 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7172740474 | ||||||||
FaxNumber: | 7172740673 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/12/2013 | ||||||||
LastUpdateDate: | 12/02/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | SW130771 | PA | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
ID Information
ID | Type | State | Issuer | Description | 102878967 | 05 | PA |   | MEDICAID |