Provider Demographics
NPI:1245813898
Name:ANNIS, SAMUEL HARRISON (LMFT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:HARRISON
Last Name:ANNIS
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2570 HOARD ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-4957
Mailing Address - Country:US
Mailing Address - Phone:908-477-5707
Mailing Address - Fax:
Practice Address - Street 1:440 SCIENCE DR STE 300
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-1064
Practice Address - Country:US
Practice Address - Phone:608-236-4460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-02
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2127-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist