Provider Demographics
NPI:1295249449
Name:SAMPSON, TERRI PETERSON (LPC)
Entity type:Individual
Prefix:MRS
First Name:TERRI
Middle Name:PETERSON
Last Name:SAMPSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 HICKORY CIR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-4151
Mailing Address - Country:US
Mailing Address - Phone:678-656-9444
Mailing Address - Fax:
Practice Address - Street 1:175 GWINNETT DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8444
Practice Address - Country:US
Practice Address - Phone:678-209-2411
Practice Address - Fax:678-212-6314
Is Sole Proprietor?:No
Enumeration Date:2017-11-27
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73288101YP2500X
GALPC011459101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX378148601Medicaid