Healthcare Provider Details

I. General information

NPI: 1093203341
Provider Name (Legal Business Name): SAMANTHA ELIZABETH HEUWAGEN MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

286 S MAIN ST STE 100
ALPHARETTA GA
30009
US

IV. Provider business mailing address

286 S MAIN ST STE 100
ALPHARETTA GA
30009-1943
US

V. Phone/Fax

Practice location:
  • Phone: 248-660-0487
  • Fax:
Mailing address:
  • Phone: 248-660-0487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT001641
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: