Provider Demographics
NPI:1659077428
Name:NELSON, SAMANTHA K (MA, LPC-MHSP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:K
Last Name:NELSON
Suffix:
Gender:F
Credentials:MA, LPC-MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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:423-467-3724
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:109 W WATAUGA AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5668
Practice Address - Country:US
Practice Address - Phone:423-232-2600
Practice Address - Fax:423-467-3644
Is Sole Proprietor?:No
Enumeration Date:2023-02-03
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5877101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional