Provider Demographics
NPI:1043938152
Name:VANDERBURG, SAMUEL KEITH (LMSW)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:KEITH
Last Name:VANDERBURG
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 TANGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MABANK
Mailing Address - State:TX
Mailing Address - Zip Code:75156-4148
Mailing Address - Country:US
Mailing Address - Phone:903-603-4003
Mailing Address - Fax:
Practice Address - Street 1:1109 N COOPER ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-5545
Practice Address - Country:US
Practice Address - Phone:817-404-2207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107145104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker