Provider Demographics
NPI:1659859841
Name:BENJAMIN, SAMANTA M
Entity Type:Individual
Prefix:MS
First Name:SAMANTA
Middle Name:M
Last Name:BENJAMIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6064 LOCKLEAR WAY
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1304
Mailing Address - Country:US
Mailing Address - Phone:352-530-7410
Mailing Address - Fax:
Practice Address - Street 1:6064 LOCKLEAR WAY
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-1304
Practice Address - Country:US
Practice Address - Phone:352-530-7410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician