Basic Information
Provider Information | |||||||||
NPI: | 1922400183 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARSH | ||||||||
FirstName: | SAMANTHA | ||||||||
MiddleName: | JOY | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA CCC-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GRAY | ||||||||
OtherFirstName: | SAMANTHA | ||||||||
OtherMiddleName: | JOY | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MA CF SLP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5305 EAGLES WAY | ||||||||
Address2: | APT 8 | ||||||||
City: | MOUNT PLEASANT | ||||||||
State: | MI | ||||||||
PostalCode: | 488587382 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9894238785 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1525 RIDGEWOOD DR | ||||||||
Address2: |   | ||||||||
City: | MIDLAND | ||||||||
State: | MI | ||||||||
PostalCode: | 486426425 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9898356333 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/19/2014 | ||||||||
LastUpdateDate: | 09/19/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 7101001058 | MI | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | 7101001058 | 01 | MI | STATE OF MICHIGAN | OTHER |