Provider Demographics
NPI:1992323430
Name:DANIELS, SAMANTHA PONCERE (MS)
Entity type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:PONCERE
Last Name:DANIELS
Suffix:
Gender:F
Credentials:MS
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 5741
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30916-5741
Mailing Address - Country:US
Mailing Address - Phone:706-373-8619
Mailing Address - Fax:706-922-3027
Practice Address - Street 1:4573 COX RD STE B
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3449
Practice Address - Country:US
Practice Address - Phone:706-922-3027
Practice Address - Fax:706-364-8996
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006854101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty