Provider Demographics
NPI:1851723480
Name:FERGUSON, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:FERGUSON
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 1:3985 STEVE REYNOLDS BLVD BLDG G
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-3001
Mailing Address - Country:US
Mailing Address - Phone:770-622-2532
Mailing Address - Fax:770-622-2534
Practice Address - Street 1:3985 STEVE REYNOLDS BLVD BLDG G
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-3001
Practice Address - Country:US
Practice Address - Phone:770-622-2532
Practice Address - Fax:770-622-2534
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-06
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008856235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist