Provider Demographics
NPI:1548077530
Name:WALL, SAMANTHA (GC-C, LMSW, CSWA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:GC-C, LMSW, CSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 4TH ST
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-3412
Mailing Address - Country:US
Mailing Address - Phone:925-212-2865
Mailing Address - Fax:
Practice Address - Street 1:808 4TH ST
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3412
Practice Address - Country:US
Practice Address - Phone:925-212-2865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-13
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORM15889104100000X
ORA162901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker