Provider Demographics
NPI:1205607546
Name:TWADDELL, SAMANTHA LAROSE (APC, NCC)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LAROSE
Last Name:TWADDELL
Suffix:
Gender:F
Credentials:APC, NCC
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:LAROSE
Other - Last Name:BALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1004 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:LANETT
Mailing Address - State:AL
Mailing Address - Zip Code:36863-6734
Mailing Address - Country:US
Mailing Address - Phone:571-379-0336
Mailing Address - Fax:
Practice Address - Street 1:1004 N 17TH ST
Practice Address - Street 2:
Practice Address - City:LANETT
Practice Address - State:AL
Practice Address - Zip Code:36863-6734
Practice Address - Country:US
Practice Address - Phone:571-379-0336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC009427101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health