Provider Demographics
NPI:1073828943
Name:BISSELL, SAMANTHA R (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:R
Last Name:BISSELL
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6035 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3256
Mailing Address - Country:US
Mailing Address - Phone:704-295-3000
Mailing Address - Fax:704-838-8494
Practice Address - Street 1:6035 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3256
Practice Address - Country:US
Practice Address - Phone:704-295-3000
Practice Address - Fax:704-838-8494
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9099235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7413417Medicaid
9276831OtherAENTA
SCSAN084Medicaid
NC16276OtherBCBSNC
SC30111355OtherSELECT HEALTH OF SC
NC16276OtherBCBSNC