Provider Demographics
NPI:1366087637
Name:ROTH, SAMARA BENENSON (LICSW, LMSW)
Entity type:Individual
Prefix:
First Name:SAMARA
Middle Name:BENENSON
Last Name:ROTH
Suffix:
Gender:F
Credentials:LICSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 ONTARIO RD NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-2627
Mailing Address - Country:US
Mailing Address - Phone:202-420-7175
Mailing Address - Fax:
Practice Address - Street 1:2333 ONTARIO RD NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-2627
Practice Address - Country:US
Practice Address - Phone:202-819-4537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-11
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104516-1104100000X
MD24176104100000X
DCLC500829001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker