=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134875503
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA BRYANT APC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2022
-----------------------------------------------------
Last Update Date | 02/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 SUN VALLEY DR STE M2
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30076-5631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-381-1687
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2121 ECTOR PL NW
-----------------------------------------------------
City | KENNESAW
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30152-6216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-290-0935
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | APC007367
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------