Provider Demographics
NPI:1124810049
Name:BRYAN, SAMANTHA (CDCA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BRYAN
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25704-2438
Mailing Address - Country:US
Mailing Address - Phone:304-964-4615
Mailing Address - Fax:
Practice Address - Street 1:303 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:OH
Practice Address - Zip Code:45619-1144
Practice Address - Country:US
Practice Address - Phone:740-451-0415
Practice Address - Fax:800-480-7578
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-19
Last Update Date:2025-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.192400101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0127415Medicaid