Provider Demographics
NPI:1578195780
Name:BOISVERT, SAMANTHA (LCSW)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BOISVERT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 RIDGEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-6527
Mailing Address - Country:US
Mailing Address - Phone:860-480-2430
Mailing Address - Fax:
Practice Address - Street 1:50 BROOKSIDE RD
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-1402
Practice Address - Country:US
Practice Address - Phone:203-755-4490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5114104100000X
CT125891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker