Provider Demographics
NPI:1962993865
Name:HARGROVE, SAMUEL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:HARGROVE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1165
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-1165
Mailing Address - Country:US
Mailing Address - Phone:812-471-1591
Mailing Address - Fax:812-471-6650
Practice Address - Street 1:1133 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714
Practice Address - Country:US
Practice Address - Phone:812-491-2615
Practice Address - Fax:812-471-6650
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
IN35000876A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker