Provider Demographics
NPI:1407185713
Name:CLARKE, SAMANTHA LOUISE (LCSW)
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:LOUISE
Last Name:CLARKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 COLEMAN ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-6318
Mailing Address - Country:US
Mailing Address - Phone:512-574-7577
Mailing Address - Fax:
Practice Address - Street 1:9111 JOLLYVILLE RD
Practice Address - Street 2:SUITE 210
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-7426
Practice Address - Country:US
Practice Address - Phone:512-323-6994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-15
Last Update Date:2012-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX520841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207375101Medicaid