Provider Demographics
NPI:1588986178
Name:WILSON, SAMANTHA L
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 W HWY 80
Mailing Address - Street 2:STE 1
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503
Mailing Address - Country:US
Mailing Address - Phone:606-425-4567
Mailing Address - Fax:606-425-5134
Practice Address - Street 1:671 W HWY 80
Practice Address - Street 2:STE 1
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503
Practice Address - Country:US
Practice Address - Phone:606-425-4567
Practice Address - Fax:606-425-5134
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY104789101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health