Provider Demographics
NPI:1093879751
Name:CHURCH, SAMANTHA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:CHURCH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CREEKVIEW ST
Mailing Address - Street 2:
Mailing Address - City:LOCUST
Mailing Address - State:NC
Mailing Address - Zip Code:28097-8507
Mailing Address - Country:US
Mailing Address - Phone:704-302-4450
Mailing Address - Fax:704-323-5222
Practice Address - Street 1:101 CREEKVIEW ST
Practice Address - Street 2:
Practice Address - City:LOCUST
Practice Address - State:NC
Practice Address - Zip Code:28097-8507
Practice Address - Country:US
Practice Address - Phone:704-302-4450
Practice Address - Fax:704-323-5222
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7716235Z00000X
SC4157235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist