Basic Information
Provider Information | |||||||||
NPI: | 1669630919 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HERNANDEZ | ||||||||
FirstName: | SAMANTHA | ||||||||
MiddleName: | GOGARTY | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15280 NW 79TH CT STE 200 | ||||||||
Address2: |   | ||||||||
City: | MIAMI LAKES | ||||||||
State: | FL | ||||||||
PostalCode: | 330165873 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3055583724 | ||||||||
FaxNumber: | 7869074485 | ||||||||
Practice Location | |||||||||
Address1: | 3661 S MIAMI AVE STE 409 | ||||||||
Address2: |   | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331334230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3058545971 | ||||||||
FaxNumber: | 3058586654 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/22/2008 | ||||||||
LastUpdateDate: | 09/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA 9473 | FL | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | 001417300 | 05 | FL |   | MEDICAID |