Provider Demographics
NPI:1093203341
Name:HEUWAGEN, SAMANTHA ELIZABETH (MFT)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ELIZABETH
Last Name:HEUWAGEN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:286 S MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-1943
Mailing Address - Country:US
Mailing Address - Phone:248-660-0487
Mailing Address - Fax:
Practice Address - Street 1:286 S MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009
Practice Address - Country:US
Practice Address - Phone:248-660-0487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-23
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001641106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist