MEDICARE: SAMANTHA LARATTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		GA

General Provider Information

NPI Number	:	1891107744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA LARATTA

Provider Business Mailing Address
First Line	:	2165 GET A WAY RD
Second Line	:
City	:	HIAWASSEE
State	:	GA
Zip	:	30546-4154
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1260 UPPER HEMBREE RD STE D
Second Line	:
City	:	ROSWELL
State	:	GA
Zip	:	30076-4611
Country	:	US
Telephone Number	:	470-387-0609
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2014
Last Update Date	:	10/23/2019

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