Provider Demographics
NPI:1114041613
Name:DEPUE, SAMANTHA FORDHAM (MED CCC-SLP, BCBA)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:FORDHAM
Last Name:DEPUE
Suffix:
Gender:F
Credentials:MED CCC-SLP, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6329 BROOKSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-2993
Mailing Address - Country:US
Mailing Address - Phone:706-577-3942
Mailing Address - Fax:706-287-1057
Practice Address - Street 1:6329 BROOKSTONE BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-2993
Practice Address - Country:US
Practice Address - Phone:706-577-3942
Practice Address - Fax:706-287-1057
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-22-62671103K00000X
235Z00000X
GASLP6138235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-22-62671OtherBEHAVIOR ANALYST CERTIFICATION BOARD
GASLP 6138OtherGA LICENSE