Healthcare Provider Details

I. General information

NPI: 1871913129
Provider Name (Legal Business Name): LEISEL SAMANTHA MARTIN-BROWN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LEISEL SAMANTHA MARTIN MD

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 SHALLOWFORD RD STE 300B
MARIETTA GA
30062-1299
US

IV. Provider business mailing address

3225 SHALLOWFORD RD STE 300B
MARIETTA GA
30062-1299
US

V. Phone/Fax

Practice location:
  • Phone: 678-734-9293
  • Fax:
Mailing address:
  • Phone: 678-734-9293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number83457
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number83457
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: