Healthcare Provider Details

I. General information

NPI: 1750831103
Provider Name (Legal Business Name): SAMANTHA JOELLE PEACOCK PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 05/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3455 PEACHTREE PKWY STE 206
SUWANEE GA
30024
US

IV. Provider business mailing address

6397 LEE HWY STE 300
CHATTANOOGA TN
37421-2564
US

V. Phone/Fax

Practice location:
  • Phone: 678-473-1081
  • Fax: 678-473-1082
Mailing address:
  • Phone: 423-238-7217
  • Fax: 423-362-8684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2124615
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: