Provider Demographics
NPI:1043808645
Name:ANDERSON, SAMANTHA (SLP)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9201 BOWDEN DR APT 303
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-8138
Mailing Address - Country:US
Mailing Address - Phone:772-403-3332
Mailing Address - Fax:
Practice Address - Street 1:12785 FOREST HILL BLVD # 8G
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-4777
Practice Address - Country:US
Practice Address - Phone:772-403-3332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ9927235Z00000X
FLSA19673235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty