Basic Information
| Provider Information | |||||||||
| NPI: | 1598176018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIRTWELL | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MA,BA,LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13 ROOSEVELT DR | ||||||||
| Address2: | |||||||||
| City: | NEWTOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064702035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033006414 | ||||||||
| FaxNumber: | 2037025283 | ||||||||
| Practice Location | |||||||||
| Address1: | 731 MAIN ST STE 122 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064682872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032617090 | ||||||||
| FaxNumber: | 2037025283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2014 | ||||||||
| LastUpdateDate: | 07/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 1736 | CT | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 13584798 | 01 | CT | CAQH | OTHER | D339123 141 E MAIN | 01 | CT | VALUE OPTIONS | OTHER | PENDING | 01 | CT | CIGNA BEHAVIORAL HEALTH | OTHER | 060669107 | 01 | CT | UBH-UNITED BEHAVIORAL HEALTH WELLMORE GRP/FACILITY | OTHER | ACTIVE MEMBER | 01 | CT | AAMFT | OTHER | PENDING | 01 | CT | MHN TRICARE NORTH | OTHER | 060669107 | 01 | CT | ANTHEM BCBS OF CT WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | UBH-CONNECTICARE WELLMORE GRP/FACILITY | OTHER | PENDING | 01 | CT | AETNA BEHAVIORAL HEALTH | OTHER | 008062567 | 05 | CT | MEDICAID | 060669017 | 01 | CT | UBH-OXFORD HEALTH/FREEDOM/LIBERTY WELLMORE GRP/FACILITY | OTHER | PENDING | 01 | CT | MHN-MANAGED HEALTH NETWORK | OTHER |