Provider Demographics
NPI:1700297256
Name:CANNON MARTIN, SAMANTHA (MSOT/L, CLT)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:
Last Name:CANNON MARTIN
Suffix:
Gender:F
Credentials:MSOT/L, CLT
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSOT/L, CLT, CLWT
Mailing Address - Street 1:145 VICTOR DR
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-2563
Mailing Address - Country:US
Mailing Address - Phone:770-310-8100
Mailing Address - Fax:
Practice Address - Street 1:145 VICTOR DR
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-2563
Practice Address - Country:US
Practice Address - Phone:770-310-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-17
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004468174400000X, 225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty