Provider Demographics
NPI:1336650332
Name:MCGINNIS, SAMUEL WADE
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:WADE
Last Name:MCGINNIS
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:PO BOX 75216
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-0216
Mailing Address - Country:US
Mailing Address - Phone:336-277-1800
Mailing Address - Fax:336-277-6981
Practice Address - Street 1:175 KIMEL PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6951
Practice Address - Country:US
Practice Address - Phone:336-277-1800
Practice Address - Fax:336-277-6981
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7736101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional