Provider Demographics
NPI:1093835183
Name:SLAGLE, SAMANTHA DENISE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:DENISE
Last Name:SLAGLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:MATNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1167 SPRATLIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-6205
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:26 MIDWAY ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1706
Practice Address - Country:US
Practice Address - Phone:423-989-4500
Practice Address - Fax:423-989-4582
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
TN5290322D00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children