Provider Demographics
NPI:1073378071
Name:MBURU, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:MBURU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 BEGGS CT NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-0617
Mailing Address - Country:US
Mailing Address - Phone:404-232-9028
Mailing Address - Fax:770-794-3126
Practice Address - Street 1:160 BEGGS CT NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-0617
Practice Address - Country:US
Practice Address - Phone:404-232-9028
Practice Address - Fax:770-794-3126
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
GA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)