1295249449 NPI number — MRS. TERRI PETERSON SAMPSON LPC

Table of content: (NPI 1285374835)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295249449 NPI number — MRS. TERRI PETERSON SAMPSON LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAMPSON
Provider First Name:
TERRI
Provider Middle Name:
PETERSON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295249449
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2103 HICKORY CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOGANVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30052-4151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-656-9444
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 GWINNETT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30046-8444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-209-2411
Provider Business Practice Location Address Fax Number:
678-212-6314
Provider Enumeration Date:
11/27/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  73288 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: LPC011459 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 378148601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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