Healthcare Provider Details

I. General information

NPI: 1093835183
Provider Name (Legal Business Name): SAMANTHA DENISE SLAGLE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SAMANTHA MATNEY

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 MIDWAY ST
BRISTOL TN
37620-1706
US

IV. Provider business mailing address

1167 SPRATLIN PARK DR
GRAY TN
37615-6205
US

V. Phone/Fax

Practice location:
  • Phone: 423-989-4500
  • Fax: 423-989-4582
Mailing address:
  • Phone: 423-467-3600
  • Fax: 423-467-3644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number5290
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5290
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: