Provider Demographics
NPI:1962642009
Name:GUILLEN, SAMANTHA A (COTA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:A
Last Name:GUILLEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5593 FORKWOOD DRIVE NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101
Mailing Address - Country:US
Mailing Address - Phone:678-923-4295
Mailing Address - Fax:770-919-1752
Practice Address - Street 1:5593 FORKWOOD DRIVE NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101
Practice Address - Country:US
Practice Address - Phone:678-923-4295
Practice Address - Fax:770-919-1752
Is Sole Proprietor?:No
Enumeration Date:2009-03-03
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23629986224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant