Provider Demographics
NPI:1447931183
Name:BRENNER, SAMANTHA (LMSW)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BRENNER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:BRENNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW
Mailing Address - Street 1:PO BOX 56
Mailing Address - Street 2:
Mailing Address - City:ARROYO SECO
Mailing Address - State:NM
Mailing Address - Zip Code:87514-0056
Mailing Address - Country:US
Mailing Address - Phone:512-876-0467
Mailing Address - Fax:
Practice Address - Street 1:NM-571 BLDG 28
Practice Address - Street 2:
Practice Address - City:EL RITO
Practice Address - State:NM
Practice Address - Zip Code:87530
Practice Address - Country:US
Practice Address - Phone:575-581-4728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-2023-0689104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker