Basic Information
Provider Information | |||||||||
NPI: | 1083375281 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WOLFORD | ||||||||
FirstName: | SAMANTHA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA CCC-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 901 WHEATFIELD DR | ||||||||
Address2: |   | ||||||||
City: | LAKE ORION | ||||||||
State: | MI | ||||||||
PostalCode: | 483623496 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2486728577 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 42804 GARFIELD RD | ||||||||
Address2: |   | ||||||||
City: | CLINTON TOWNSHIP | ||||||||
State: | MI | ||||||||
PostalCode: | 480381656 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5863232957 | ||||||||
FaxNumber: | 5863230022 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/10/2022 | ||||||||
LastUpdateDate: | 01/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 7101002237 | MI | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | 1730363573 | 01 | MI | CRAWL, WALK, JUMP, RUN THERAPY CLINIC, LLC | OTHER |