Provider Demographics
NPI:1003534710
Name:MOORE, SAMANTHA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 TRELAGO WAY APT 201
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4319
Mailing Address - Country:US
Mailing Address - Phone:727-641-4114
Mailing Address - Fax:
Practice Address - Street 1:351 N ORLANDO AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2911
Practice Address - Country:US
Practice Address - Phone:407-303-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA20378235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist