Provider Demographics
NPI:1538527700
Name:SPEED, SAMANTHA NICOLE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:NICOLE
Last Name:SPEED
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:NICOLE
Other - Last Name:CARNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11307 JEFFERSON CIR N
Mailing Address - Street 2:
Mailing Address - City:CHAMBLEE
Mailing Address - State:GA
Mailing Address - Zip Code:30341-2699
Mailing Address - Country:US
Mailing Address - Phone:980-622-9735
Mailing Address - Fax:
Practice Address - Street 1:1640 POWERS FERRY RD SE STE 250
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-5491
Practice Address - Country:US
Practice Address - Phone:704-873-1011
Practice Address - Fax:704-832-2253
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-03
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA12038101YM0800X, 101YP2500X
GAAPC006696101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional