Provider Demographics
NPI:1639765050
Name:MCINNIS, SAMANTHA (LPC, NCC, MS)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:
Last Name:MCINNIS
Suffix:
Gender:F
Credentials:LPC, NCC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:287 14TH ST. NW
Mailing Address - Street 2:#9
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-5370
Mailing Address - Country:US
Mailing Address - Phone:678-801-6313
Mailing Address - Fax:
Practice Address - Street 1:287 14TH ST. NW
Practice Address - Street 2:#9
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-5370
Practice Address - Country:US
Practice Address - Phone:646-229-1049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-19
Last Update Date:2020-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006111101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional