Healthcare Provider Details

I. General information

NPI: 1528628104
Provider Name (Legal Business Name): SHASHONDALYN SHANAY SAMUELS CM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1944 BRANNAN RD
MCDONOUGH GA
30253-4310
US

IV. Provider business mailing address

2400 HONEY CT
MCDONOUGH GA
30252-8503
US

V. Phone/Fax

Practice location:
  • Phone: 678-289-6981
  • Fax:
Mailing address:
  • Phone: 470-923-0252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC016534
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: