Provider Demographics
NPI:1760016984
Name:BLAND, SAMIRA
Entity Type:Individual
Prefix:
First Name:SAMIRA
Middle Name:
Last Name:BLAND
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 1:315 W PONCE DE LEON AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2481
Mailing Address - Country:US
Mailing Address - Phone:770-609-6976
Mailing Address - Fax:
Practice Address - Street 1:315 W PONCE DE LEON AVE STE 300
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2481
Practice Address - Country:US
Practice Address - Phone:770-609-6976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA052338105OtherDRIVER LICENSE