Provider Demographics
NPI:1316124928
Name:PRIDE, SAMUEL K
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:K
Last Name:PRIDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 819
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:GA
Mailing Address - Zip Code:39870-0819
Mailing Address - Country:US
Mailing Address - Phone:229-224-4883
Mailing Address - Fax:
Practice Address - Street 1:1102 SMITH AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5739
Practice Address - Country:US
Practice Address - Phone:229-225-4335
Practice Address - Fax:229-225-4374
Is Sole Proprietor?:No
Enumeration Date:2008-01-25
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0024281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical