Provider Demographics
NPI:1083375281
Name:WOLFORD, SAMANTHA (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WOLFORD
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 1:901 WHEATFIELD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-3496
Mailing Address - Country:US
Mailing Address - Phone:248-672-8577
Mailing Address - Fax:
Practice Address - Street 1:42804 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1656
Practice Address - Country:US
Practice Address - Phone:586-323-2957
Practice Address - Fax:586-323-0022
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101002237235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1730363573OtherCRAWL, WALK, JUMP, RUN THERAPY CLINIC, LLC