Provider Demographics
NPI:1295509438
Name:JOHNSON, SAMANTHA BROOKE
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:BROOKE
Last Name:JOHNSON
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 1:870 HOLLIDAY DAM RD
Mailing Address - Street 2:
Mailing Address - City:HONEA PATH
Mailing Address - State:SC
Mailing Address - Zip Code:29654-9430
Mailing Address - Country:US
Mailing Address - Phone:864-367-4351
Mailing Address - Fax:
Practice Address - Street 1:870 HOLLIDAY DAM RD
Practice Address - Street 2:
Practice Address - City:HONEA PATH
Practice Address - State:SC
Practice Address - Zip Code:29654-9430
Practice Address - Country:US
Practice Address - Phone:864-367-4351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
SC105855807103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst