Basic Information
| Provider Information | |||||||||
| NPI: | 1306103445 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34 WELCH AVE | ||||||||
| Address2: | |||||||||
| City: | WINDSOR | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060952935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607413001 | ||||||||
| FaxNumber: | 8607418332 | ||||||||
| Practice Location | |||||||||
| Address1: | 113 ELM ST STE 204 | ||||||||
| Address2: | |||||||||
| City: | ENFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060823739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607413001 | ||||||||
| FaxNumber: | 0867418332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2012 | ||||||||
| LastUpdateDate: | 04/13/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 002170 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | A412956 | 01 | CT | OXFORD | OTHER | 4553929 | 01 | CT | AETNA | OTHER | 201366 | 01 | CT | MNH | OTHER | 004121141 | 05 | CT | MEDICAID | 321137/A324839 | 01 | CT | VALUE OPTIONS | OTHER |