=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083370845
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA CIERRA RANKINE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2021
-----------------------------------------------------
Last Update Date | 08/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3120 LAKE PORT DR
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30039-5444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-305-4142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3120 LAKE PORT DR
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30039-5444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-305-4142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-24-77566
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------