Healthcare Provider Details

I. General information

NPI: 1104147651
Provider Name (Legal Business Name): ALAINA SAMPLES CONNER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ALAINA SAMPLES CONNER ALAINA SAMPLES

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 06/03/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CANDLER
GAINESVILLE GA
30501
US

IV. Provider business mailing address

610 CANDLER ST
GAINESVILLE GA
30501-3334
US

V. Phone/Fax

Practice location:
  • Phone: 770-569-3839
  • Fax:
Mailing address:
  • Phone: 770-569-3839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC005800
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY004369
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: