Provider Demographics
NPI:1023482015
Name:WOLLENZIEN, SAMUEL (LCSW)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:WOLLENZIEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4065 E YAKIMA WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-5020
Mailing Address - Country:US
Mailing Address - Phone:435-713-5797
Mailing Address - Fax:
Practice Address - Street 1:GEB 3377
Practice Address - Street 2:
Practice Address - City:LANDSTUHL
Practice Address - State:EU
Practice Address - Zip Code:66849
Practice Address - Country:DE
Practice Address - Phone:314-590-7267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-14
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8292525-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical