Provider Demographics
NPI:1407204100
Name:CHITTENDEN, SAMANTHA (LCSW)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:CHITTENDEN
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 1:1731 VAN DYKE ST APT 1
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-2633
Mailing Address - Country:US
Mailing Address - Phone:616-446-2265
Mailing Address - Fax:
Practice Address - Street 1:1731 VAN DYKE ST APT 1
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-2633
Practice Address - Country:US
Practice Address - Phone:616-446-2265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI96251041C0700X
MI68010995121041C0700X
MI68011077741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100081251Medicaid