Provider Demographics
NPI:1235002304
Name:COLLARD, SAMANTHA NICOLE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:NICOLE
Last Name:COLLARD
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 1:15980 BLUEBIRD LN
Mailing Address - Street 2:
Mailing Address - City:WAGRAM
Mailing Address - State:NC
Mailing Address - Zip Code:28396-9690
Mailing Address - Country:US
Mailing Address - Phone:910-217-3374
Mailing Address - Fax:
Practice Address - Street 1:130 TURNBERRY WAY
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8508
Practice Address - Country:US
Practice Address - Phone:704-440-3580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-25
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician