Provider Demographics
NPI:1699535484
Name:ROBERTS, SAMANTHA CANNON (LCSW, LCDC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:CANNON
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LCSW, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 BLUE RIDGE DR STE 300
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-1002
Mailing Address - Country:US
Mailing Address - Phone:512-843-1154
Mailing Address - Fax:
Practice Address - Street 1:1502 BLUE RIDGE DR STE 300
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-1002
Practice Address - Country:US
Practice Address - Phone:512-843-1154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16660101YA0400X
TX1059971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)