Healthcare Provider Details

I. General information

NPI: 1710720297
Provider Name (Legal Business Name): SAMARA FOSTER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5635 PEACHTREE PKWY STE 180
PEACHTREE CORNERS GA
30092-2823
US

IV. Provider business mailing address

445 WINN WAY
DECATUR GA
30030-1707
US

V. Phone/Fax

Practice location:
  • Phone: 770-389-8100
  • Fax:
Mailing address:
  • Phone: 404-294-3835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW009093
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: